Remote command center for patient monitoring

ABSTRACT

A remote command center for providing services to geographically dispersed hospitalized patients. A datastore accessible to the remote command center receives patient data from geographically dispersed hospitalized patients. Monitored data elements of geographically dispersed hospitalized patients are also received at the remote command center and stored in the datastore. A smart alert module generates and applies patient specific rules to selected data elements. If a patient-specific rule for a hospitalized patient has been contravened, an alert is issued from the remote command center. A patient care module displays selected data elements of the hospitalized patients at the remote command center. A decision support module applies decision support algorithms to selected data elements of a hospitalized patient and to user input to provide patient care advice. Patient care advice comprises a diagnosis, a method of treatment, and a laboratory protocol. The decision support module may also write orders for medication, laboratory protocols and surgical procedures.

RELATIONSHIP TO OTHER APPLICATIONS

This application is a continuation in part of application Ser. No.10/654,668 filed Sep. 04, 2003 and a continuation in part of applicationSer. No. 10/946,548 filed Sep. 21, 2004, both of which are continuationsin part of application Ser. No. 09/443,072 filed Nov. 18, 1999, now U.S.Pat. No. 6,804,656 issued Oct. 12, 2004, which claims the benefit ofU.S. Provisional Application No. 60/141,520, filed Jun. 23, 1999. The09/443,072 application is hereby incorporated by reference in itsentirety for all purposes.

FIELD OF THE INVENTION

This invention relates generally to the care of patients in IntensiveCare Units (ICUs). More particularly this invention is a system andmethod for care of the critically ill that combines a real-time,multi-node telemedicine network and an integrated, patient caremanagement system to enable specially-trained Intensivists to provide24-hour/7-day-per-week patient monitoring and management to multiple,geographically dispersed ICUs from both on-site and remote locations.

BACKGROUND OF THE INVENTION

While the severity of illness of ICU patients over the past 15 years hasincreased dramatically, the level of and type of physician coverage inmost ICUs has remained constant. Most ICU patients receive brief minutesof attention during morning rounds from physicians with limited criticalcare experience. During the remainder of the day and night, nurses arethe primary caregivers, with specialists called only after patientconditions have started to deteriorate. The result of this mismatchbetween severity of illness and physician coverage is an unacceptablyhigh ICU mortality rate (10% nationwide), and a high prevalence ofavoidable errors that result in clinical complications. In 1998, anInstitute of Medicine Roundtable determined that avoidable patientcomplications were the single largest problem in medical care delivery.In another prominent 1998 study of 1000 patients, 46% experienced anavoidable adverse event in care, with 40% of these errors resulting inserious disability or death.

The physicians who can remedy this situation are in critically shortsupply. Numerous studies have shown that Intensivists (physicians whohave trained and board certified in Critical Care Medicine) can markedlyimprove patient outcomes. However, only one-third of all ICU patientsever has an Intensivist involved in their care, and the number ofIntensivists would need to increase tenfold (nationally) to provide24-hour coverage to all ICU patients. With the rapid aging of thepopulation, this shortfall of expertise is going to increasedramatically.

Even where Intensivists are present (and especially where they are not),patients suffer from unnecessary variation in practice. There is littleincentive for physicians to develop and conform to evidence-based bestpractices (it takes significant work and a change in behavior to developand implement them). This variation contributes to sub-optimal outcomes,in both the quality and cost of care delivered to ICU patients.

What is needed is a redesigning of the critical care regimen offered topatients in an ICU. Rather than the consultative model where a periodicvisit takes place and the doctor then goes away, a more active 24-hourintensivist managed care is required. Further, technology that leveragesthe intensivists' expertise and standardizes the care afforded topatients in an ICU is required. Further, continuous feedback to improvethe practice of intensivists in an ICU is necessary to provide theintervention required to minimize adverse events. This invention seeksto provide new methods for managing and delivering care to thecritically ill.

Attempts to automate various aspects of patient care have been thesubject of various inventions. For example, U.S. Pat. No. 5,868,669 toIliff was issued for “Medical Diagnostic and Treatment Advice System.”The disclosed invention is for a system and method for providingknowledge based medical diagnostic and treatment advice to the generalpublic over a telephone network.

U.S. Pat. No. 5,823,948 to Ross, Jr. et al was issued for “MedicalRecords Documentation, Tracking and Order Entry System”. The disclosedinvention is for a system and method that computerizes medical records,documentation, tracking and order entries. A teleconferencing system isemployed to allow patient and medical personnel to communicate with eachother. A video system can be employed to videotape a patient's consent.

U.S. Pat. No. 4,878,175 to Norden-Paul et al. was issued for “Method forGenerating Patient-Specific Flowsheets By Adding/Deleting Parameters.”The disclosed invention is for an automated clinical records system forautomated entry of bedside equipment results, such as an EKG monitor,respirator, etc. The system allows for information to be entered at thebedside using a terminal having input means and a video display.

U.S. Pat. No. 5,544,649 to David et al. was issued for “AmbulatoryPatient Health Monitoring Techniques Utilizing Interactive VisualCommunications.” The disclosed invention is for an interactive visualsystem, which allows monitoring of patients at remote sites, such as thepatient's home. Electronic equipment and sensors are used at the remotesite to obtain data from the patient, which is sent to the monitoringsite. The monitoring site can display and save the video, audio andpatient's data.

U.S. Pat. No. 5,867,821 to Ballantyne et al. was issued for “Method andApparatus for Electronically Accessing and Distributing Personal HealthCare Information and Services in Hospitals and Homes.” The disclosedinvention is for an automated system and method for distribution andadministration of medical services, entertainment services, andelectronic health records for health care facilities.

U.S. Pat. No. 5,832,450 to Myers et al. issued for “Electronic MedicalRecord Using Text Database.” The disclosed invention is for anelectronic medical record system, which stores data about patientencounters arising from a content generator in freeform text.

U.S. Pat. No. 5,812,983 to Kumagai was issued for “Computer Medical Fileand Chart System.” The disclosed invention is for a system and methodwhich integrates and displays medical data in which a computer programlinks a flow sheet of a medical record to medical charts.

U.S. Pat. No. 4,489,387 to Lamb et al. was issued for “Method andApparatus for Coordinating Medical Procedures.” The disclosed inventionis for a method and apparatus that coordinates two or more medical teamsto evaluate and treat a patient at the same time without repeating thesame steps.

U.S. Pat. No. 4,731,725 to Suto et al. issued for “Data ProcessingSystem which Suggests a Pattern of Medical Tests to Reduce the Number ofTests Necessary to Confirm or Deny a Diagnosis.” The disclosed inventionis for a data processing system that uses decision trees for diagnosinga patient's symptoms to confirm or deny the patient's ailment.

U.S. Pat. No. 5,255,187 to Sorensen issued for “Computer Aided MedicalDiagnostic Method and Apparatus.” The disclosed invention is for aninteractive diagnostic system which relies on color codes which signifythe presence or absence of the possibility of a disease based on thesymptoms a physician provides the system.

U.S. Pat. No. 5,553,609 to Chen et al. issued for “Intelligent RemoteVisual Monitoring System for Home Health Care Service.” The disclosedinvention is for a computer-based remote visual monitoring system, whichprovides in-home patient health care from a remote location via ordinarytelephone lines.

U.S. Pat. No. 5,842,978 to Levy was issued for “Supplemental AudioVisual Emergency Reviewing Apparatus and Method.” The disclosedinvention is for a system which videotapes a patient and superimposesthe patient's vital statistics onto the videotape.

While these inventions provide useful records management and diagnostictools, none of them provides a comprehensive method for monitoring andproviding real time critical care at disparate ICUs. In short, they areNOT designed for critical care. Further, none of these inventionsprovide for the care of a full time intensivist backed by appropriatedatabase and decision support assistance in the intensive careenvironment. What would be useful is a system and method for providingcare for the critically ill that maximizes the presence of anintensivist trained in the care of the critically ill. Further such asystem would standardize the care in ICUs at a high level and reduce themortality rate of patients being cared for in ICUs.

SUMMARY OF THE INVENTION

The present invention provides a core business of Continuous Expert CareNetwork (CXCN) solution for hospital intensive care units (ICUs). Thise-solution uses network, database, and decision support technologies toprovide 24-hour connectivity between Intensivists and ICUs. The improvedaccess to clinical information and continuous expert oversight leads toreduced clinical complications, fewer medical errors, reduced mortality,reduced length of stay, and reduced overall cost per case.

The technology of the present invention as explained below can beimplemented all at once or in stages. Thus the technology, as more fullyexplained below is available in separate components to allow for thefact that hospitals may not be able to implement all of the technologyat once. Thus modular pieces (e.g. videoconferencing, vital signmonitoring with smart alarms, hand-held physician productivity tools,etc.) can be implemented, all of which can add value in a stand-alonecapacity. First amongst these offerings will be an Intensivist DecisionSupport System, a stand-alone software application that codifiesevidence-based, best practice medicine for 150 common ICU clinicalscenarios. These support algorithms are explained more fully below.

The “Command Center” model, again as more fully set forth below, willultimately give way to a more distributed remote management model whereIntensivists and other physicians can access ICU patients and clinicians(voice, video, data) from their office or home. In this scenario, thepresent invention will be available in hospital applications thatcentralize ICU information, and offer physicians web-based applicationsthat provide them with real-time connectivity to this information and tothe ICUs. This access and connectivity will enable physicians to monitorand care for their patients remotely. These products will be naturalextensions and adaptations of the present invention and the existingapplications disclosed herein that those skilled in the art willappreciate and which do not depart from the scope of the invention asdisclosed herein.

The present invention addresses these issues and shortcomings of theexisting situation in intensive care, and its shortfalls via two majorthrusts. First, an integrated video/voice/data network applicationenables continuous real-time management of ICU patients from a remotesetting. Second, a client-server database application—integrated to theremote care network—provides the data analysis, data presentation,productivity tools and expert knowledge base that enables a singleIntensivist to manage the care of up to 40 patients simultaneously. Thecombination of these two thrusts—care management from a remote locationand new, technology-enhanced efficiency of Intensivist efforts—allowshealth care systems to economically raise the standard of care in theirICUs to one of 24.times.7 continuous Intensivist oversight.

It is therefore an object of the present invention to reduce avoidablecomplications in an ICU.

It is a further object of the present invention to reduce unexplainedvariations in resource utilization in an ICU.

It is a further objective of the present invention to mitigate theserious shortage of intensivists.

It is yet another objective of the present invention to reduce theoccurrence of adverse events in an ICU.

It is a further objective of the present invention to standardize thecare at a high level among ICUs.

It is yet another objective of the present invention to reduce the costof ICU care.

It is yet another objective of the present invention to dramaticallydecrease the mortality in an ICU.

It is yet another objective of the present invention to bringinformation from the ICU to the intensivist, rather than bring theintensivist to the ICU.

It is a further objective of the present invention to combinetele-medical systems comprising two-way audio/video communication with acontinuous real time feed of clinical information to enable theintensivist to oversee care within the ICU.

It is a further objective of the present invention to allow intensiviststo monitor ICUs from a site remote from each individual ICU.

It is a further objective of the present invention to bring organizeddetailed clinical information to the intensivist, thereby providingstandardized care in the ICU.

It is yet another objective of the present invention to utilizeknowledge-based software to use rules, logic, and expertise to providepreliminary analysis and warnings for the intensivists.

The present invention comprises a command center/remote location, whichis electronically linked to ICUs remote from the command center/remotelocation. The command center/remote location is manned by intensivists24 hours a day, seven days per week. Each ICU comprises a nurse'sstation, to which data flows from individual beds in the ICU. Eachpatient in the ICU is monitored by a video camera, as well as byclinical monitors typical for the intensive care unit. These monitorsprovide constant real time patient information to the nurse's station,which in turn provides that information over a dedicated T-1 (highbandwidth) line to the ICU command center/remote location. As notedearlier, the command center/remote location is remote from the ICU,thereby allowing the command center/remote location to simultaneouslymonitor a number of patients in different ICUs remote from the commandcenter/remote location.

At each command center/remote location, video monitors exist so that theintensivist can visually monitor patients within the ICU. Further, theintensivist can steer and zoom the video camera near each patient sothat specific views of the patient may be obtained, both up close andgenerally. Audio links allow intensivists to talk to patients and staffat an ICU bed location and allow those individuals to converse with theintensivist.

Clinical data is constantly monitored and presented to the commandcenter/remote location in real time so that the intensivist can not onlymonitor the video of the patient but also see the vital signs astransmitted from the bedside. The signals from the clinical data andvideo data are submitted to a relational database, which comprises 1)standardized guidelines for the care of the critically ill, 2) variousalgorithms to support the intensive care regimen, 3) order writingsoftware so that knowledge-based recommendations and prescriptions formedication can be made based upon the clinical data, and 4)knowledge-based vital-sign/hemodynamic algorithms that key theintensivist to engage in early intervention to minimize adverse events.

The advantage of the present invention is that intensivists see allpatients at a plurality of ICU's at all times. Further, there is acontinuous proactive intensivist care of all patients within the ICU,thereby minimizing adverse events. Intervention is triggered byevidence-based data-driven feedback to the intensivist so thatstandardized care can be provided across a plurality of ICUs.

The economic benefits of the present invention are manifold. For thefirst time, 24-hour a day, seven day a week intensivist care forpatients in an ICU can be obtained. Further, more timely interventionsin the care of the patients can be created by the knowledge-basedguidelines of the present invention, thereby minimizing complicationsand adverse events. This in turn will lead to a reduced mortality withinthe ICU, and hence, a reduced liability cost due to the dramaticreduction in avoidable errors in health care.

By providing timely interventions, the length of stay within the ICU canbe greatly reduced, thereby allowing more critically ill patients to becared for in the ICU.

In addition, by reviewing and standardizing the care afforded topatients in an ICU, a more standardized practice across a variety ofICUs can be achieved. This will lead to more cost-effective care withinthe ICU, and reduced ancillary cost for the care of the critically ill.

The overall architecture of the present invention comprises a “pod.” Thepod comprises a tele-medicine command center/remote location connectedto a plurality multiple ICUs at various locations. The connectionbetween the command center/remote location and the ICUs is via adedicated wide-area network linking the ICUs to the commandcenter/remote location and a team of intensivists who integrate theirservices to provide 24-hour, seven day a week care to all of the podICUs.

The pod is connected via a wide-area network using dedicated T-1 lines,for example, with redundant backup. This network provides reliable, highspeed secure transmission of clinical data and video/audio signalsbetween each patient room and the command center/remote location. Theuse of a T-1 line is not meant as a limitation. It is expected that moreand higher bandwidth networks will become available. Such high bandwidthnetworks would come within the scope of the invention as well.

Each patient room is equipped with a pan/tilt/zoom video camera withaudio and speaker to enable full videoconferencing capability. Inaddition, computer workstations are dedicated for exclusive physicianuse in each ICU, preferably at the nurse's station. Intensivists use theworkstations to view patient information, consult decision supportinformation, record their notes, and generate patient orders.

The patient management software used by intensivists is provided acrossthe pod. Updates and changes made to the record are available at boththe ICU and the command center/remote location for any given patient.

Each command center/remote location contains at least threeworkstations: one for the intensivist, one for the critical careregistered nurse, and one for a clerk/administrative person.

The intensivist workstation comprises separate monitors for displayingICU video images of patients and/or ICU personnel, output from bedsidemonitoring equipment, patient clinical data comprising history, notes,lab reports, etc., and decision support information. The staff at thecommand center/remote location are able to activate and control thecameras in each patient's room so that appropriate visual views of thepatient can be generated.

Intensivists are able to switch between rooms and patients and canmonitor at least two rooms simultaneously via the video screens. Patientdata such as X-ray and ECG images are scanned and transmitted to thecommand center/remote location upon request of the intensivist.

Remote patient management is utilized in the present invention'scritical care program to supplement traditional onsite care. Therationale underlying the remote patient management of the presentinvention is that critically ill patients are inherently unstable andrequire continuous expert care that is not now offered in existing ICUmonitoring regimens. Further, remote monitoring allows a singleintensivist to care for patients in multiple ICU locations, therebycreating an efficiency that makes continuous care feasible.

Remote intensivist care of the present invention is proactive.Intensivists will order needed therapies and check results of tests andmonitor modalities in a more timely fashion than is currently offered.Patients can be observed visually when needed using the ceiling-mountedcameras in each room.

Command center/remote location personnel communicate with ICU staffthrough videoconferencing and through “hot phones,” which are dedicatedtelephones directly linked between the command center/remote locationand the ICU. These communications links are used to discuss patient careissues and to communicate when a new order has been generated.

Intensivists document important events occurring during their shift inprogress notes generated on the command center/remote location computerterminal.

Intensivists detect impending problems by intermittently screeningpatient data, including both real time and continuously stored vitalsign data. Patient severity of illness determines the frequency withwhich each patient's data is reviewed by the intensivists.

Embodiments of the present invention provide a system for providingcontinuous, expert network health care services from a remote location.The system comprises a plurality of health care locations, at least oneremote command center for managing healthcare at said plurality ofhealth care locations, and at least one network. The plurality of healthcare locations are electronically connected to said at least one remotecommand center by the network. The at least one remote command centerprovides intensivist monitoring of the plurality of health carelocations 24 hours per days seven days per week.

The remote command center further comprises a patient care managementsystem for monitoring and treating individual patients at any of saidplurality of healthcare locations. The patient care management systemfurther comprises a data server/data warehouse for storing and analyzingdata from the at least one remote command center.

Each of the plurality of health care locations further comprises patientmonitoring equipment electronically connected to the at least one remotecommand center over the network. In another embodiment of the presentinvention each health care location further comprises a nurses' stationelectronically connected to said monitoring equipment and to the atleast one remote command center over the network. In still anotherembodiment of the present invention, the healthcare locations compriseintensive care units (ICU's).

Optionally, the patient care management system further comprises arelational database for storing a plurality of decision supportalgorithms and for prompting intensivists to provide care to patientsbased upon any of the decision support algorithms. The algorithms areselected from the group consisting of algorithms for treating AcalculousCholecystitis, Acute Pancreatitis Algorithms, Acute RenalFailure-Diagnosis, Acute Renal Failure-Management & Treatment, AdrenalInsufficiency. Agitation and Anxiety, Depression & Withdrawal,Aminoglycoside Dosing and Therapeutic Monitoring, an Amphotericin-BTreatment Guidelines, Analgesia, Antibiotic Classification & Costs,Antibiograms Algorithm, Antibiotic associated Colitis Algorithm, ARDS:Hemodynamic Management, ARDS: Steroid Use, ARDS: Ventilator Strategies,Asthma, Bleeding Patient, Bloodstream Infections, Blunt Cardiac Injury,Bradyarrhythmias, Brain Death, Bronchodilator Use in VentilatorPatients, Bronchoscopy & Thoracentesis Guidelines, Candiduria,Cardiogenic Shock, CardioPulmonary Resuscitation Guideline, CatheterRelated Septicemia, a Catheter Replacement Strategies, Cervical CordInjury, Congestive Heart Failure, COPD Exacerbation & Treatment, CXR(Indications), Dealing with Difficult patients and families, DiabeticKetoacidosis, Dialysis, Diuretic Use, Drug Changes with RenalDysfunction, Emergency Cardiac Pacing, Endocarditis Diagnosis andTreatment, Endocarditis Prophylaxis, End of Life Decisions, EndotrachealTubes & Tracheotomy, Ethical Guidelines, Febrile Neutropenia, FUO, FluidResuscitation, Guillain-Barre Syndrome, Heparin, Heparin-InducedThrombocytopenia, Hepatic Encephalopathy, Hepatic Failure, HIV+PatientInfections, Hypercalcemia Diagnosis and Treatment, Hyperglycemia InsulinTreatment, Hyperkalemia: Etiology & Treatment, Hypernatremia: Etiology &Treatment, Hypertensive Crisis, Hypokalemia: Etiology & Treatment,Hyponatremia: Etiology & Treatment, Hypothermia, Identification ofCervical Cord Injury, Implantable Cardio-defibrillator, Intra-AorticBalloon Device, Intracerebral Hemorrhage, Latex Allergy, MagnesiumAdministration, Management of Hypotension, Inotropes, Management ofPatients with Ascites, Empiric Meningitis, Meningitis, a MyastheniaGravis, Myocardial Infarction, Myocardial Infarction with left bundlebranch block, Necrotizing Soft Tissue Infections, NeuromuscularBlockers, Neuromuscular Complications of Critical Illness,Non-Infectious Causes of Fever, Non-Traumatic Coma, Noninvasive Modes ofVentilation, Nutritional Management, Obstetrical Complication, Oliguria,Open Fractures, Ophthalmic Infections, Organ Procurement Guidelines, PACatheter Guideline and Troubleshooting, Pancreatitis, PenetratingAbdominal Injury, Penetrating Chest Injury, Penicillin Allergy,Permanent Pacemaker and Indications, Pneumonia Community Acquired,Pneumonia Hospital Acquired, Post-Op Bleeding, Post-Op Hypertension,Post-Op Management of Abdominal Post-Op Management of Carotid, Post-OpManagement of Open Heart, Post-Op Management of Thoracotomy, Post-OpMyocardial Ischemia (Non-Cardiac Arrhythmias after Cardiac Surgery),Post-Op Power Weaning, Pressure Ulcers, Pulmonary Embolism Diagnosis,Pulmonary Embolism Treatment, Respiratory Isolation, Sedation, Seizure,Status Epilepticus, Stroke, Sub-Arachnoid Hemorrhage, Supra-VentricularTachyarrhythmia, Supra-Ventricular Tachycardia, Wide Complex QRSTachycardia, Therapeutic Drug Monitoring, Thrombocytopenia, ThrombolyticTherapy, Transfusion Guidelines, Traumatic Brain Injury, Assessment ofSedation, Sedation, Septic Shock, Bolus Sliding, Scale Midazolam, ShortTerm Sedation Process, Sinusitis, SIRS, Spinal Cord Injury, SteroidReplacement Strategy, Thyroid Disease, Transplant Infection Prophylaxis,Transplant Related Infections, Treatment of Airway Obstruction, UnknownPoisoning, Unstable Angina, Upper GI Bleeding Stress Prophylaxis,Vancomycin, Upper GI Bleeding Non-Variceal, Upper GI Bleeding Variceal,Use of Hematopoietic Growth Factors, Ventilator Weaning, VentilatorWeaning Protocol, Venous Thrombosis Diagnosis and Treatment, VenousThromboembolism Prophylaxis, Ventricular Arrhythmia, Warfarin, WarfarinDosing, and Wound Healing Strategies.

In yet another embodiment of the present invention, the patient caremanagement system further comprises order writing software for providingknowledge-based recommendations and prescriptions for medication basedupon the clinical data. In another embodiment of the present invention,the patient care management system further comprises knowledge-basedvital sign/hemodynamic algorithms that prompt said intensivist to engagein early intervention.

Embodiments of the present invention provide methods for continuousexpert critical care. Patients are monitored in a plurality of ICU's.Information from the patient monitoring is communicated to at least onecommand center over a first network. The information from the patientmonitoring is received and analyzed at the command center over the firstnetwork; and guidance is provided from the command center to theplurality of ICU's to take actions regarding patient care. In anotherembodiment of the present invention, providing guidance from the commandcenter further comprises an intensivist reviewing decision supportalgorithms that provide guidance for treating a plurality of criticalcare conditions. The algorithms are taken from the group consisting ofalgorithms for treating Acalculous Cholecystitis, Acute PancreatitisAlgorithm, Acute Renal Failure-Diagnosis, Acute Renal Failure-Management& Treatment, Adrenal Insufficiency, Agitation and Anxiety, Depression &Withdrawal, Aminoglycoside Dosing and Therapeutic Monitoring, anAmphotericin-B Treatment Guidelines, Analgesia, AntibioticClassification & Costs, Antibiograms Algorithm, Antibiotic associatedColitis Algorithm, ARDS: Hemodynamic Management, ARDS: Steroid Use,ARDS: Ventilator Strategies, Asthma, Bleeding Patient, BloodstreamInfections, Blunt Cardiac Injury, Bradyarrhythmias, Brain Death,Bronchodilator Use in Ventilator Patients, Bronchoscopy & ThoracentesisGuidelines, Candiduria, Cardiogenic Shock, CardioPulmonary ResuscitationGuideline, Catheter Related Septicemia, a Catheter ReplacementStrategies, Cervical Cord Injury, Congestive Heart Failure, COPDExacerbation & Treatment, CXR (Indications), Dealing with Difficultpatients and families, Diabetic Ketoacidosis, Dialysis, Diuretic Use,Drug Changes with Renal Dysfunction, Emergency Cardiac Pacing,Endocarditis Diagnosis and Treatment, Endocarditis Prophylaxis, End ofLife Decisions, Endotracheal Tubes & Tracheotomy, Ethical Guidelines,Febrile Neutropenia, FUO, Fluid Resuscitation, Guillain-Barre Syndrome,Heparin, Heparin-Induced Thrombocytopenia, Hepatic Encephalopathy,Hepatic Failure, HIV+Patient Infections, Hypercalcemia Diagnosis andTreatment, Hyperglycemia Insulin Treatment, Hyperkalemia: Etiology &Treatment, Hypernatremia: Etiology & Treatment, Hypertensive Crisis,Hypokalemia: Etiology & Treatment, Hyponatremia: Etiology & Treatment,Hypothermia, Identification of Cervical Cord Injury, ImplantableCardio-defibrillator, Intra-Aortic Balloon Device, IntracerebralHemorrhage, Latex Allergy, Magnesium Administration, Management ofHypotension, Inotropes, Management of Patients with Ascites, EmpiricMeningitis, Meningitis, a Myasthenia Gravis, Myocardial Infarction,Myocardial Infarction with left bundle branch block, Necrotizing SoftTissue Infections, Neuromuscular Blockers, Neuromuscular Complicationsof Critical Illness, Non-Infectious Causes of Fever, Non-Traumatic Coma,Noninvasive Modes of Ventilation, Nutritional Management, ObstetricalComplications, Oliguria, Open Fractures, Ophthalmic Infections, OrganProcurement Guidelines, PA Catheter Guideline and Troubleshooting,Pancreatitis, Penetrating Abdominal Injury, Penetrating Chest Injury,Penicillin Allergy, Permanent Pacemaker and Indications, PneumoniaCommunity Acquired, Pneumonia Hospital Acquired, Post-Op Bleeding,Post-Op Hypertension, Post-Op Management of Abdominal, Post-OpManagement of Carotid, Post-Op Management of Open Heart, Post-OpManagement of Thoracotomy, Post-Op Myocardial Ischemia, (Non-CardiacArrhythmias after Cardiac Surgery), Post-Op Power Weaning, PressureUlcers, Pulmonary Embolism Diagnosis, Pulmonary Embolism Treatment,Respiratory Isolation, Sedation, Seizure, Status Epilepticus, Stroke,Sub-Arachnoid Hemorrhage, Supra-Ventricular Tachyarrhythmia,Supra-Ventricular Tachycardia, Wide Complex QRS Tachycardia, TherapeuticDrug Monitoring, Thrombocytopenia, Thrombolytic Therapy, TransfusionGuidelines, Traumatic Brain Injury, Assessment of Sedation, Sedation,Septic Shock, Bolus Sliding Scale Midazolam, Short Term SedationProcess, Sinusitis, SIRS, Spinal Cord Injury, Steroid ReplacementStrategy, Thyroid Disease, Transplant Infection Prophylaxis, TransplantRelated Infections, Treatment of Airway Obstruction, Unknown Poisoning,Unstable Angina, Upper GI Bleeding Stress Prophylaxis, Vancomycin, UpperGI Bleeding Non-Variceal, Upper GI Bleeding Variceal, Use ofHematopoietic Growth Factors, Ventilator Weaning, Ventilator WeaningProtocol, Venous Thrombosis Diagnosis and Treatment, VenousThromboembolism Prophylaxis, Ventricular Arrhythmia, Warfarin, WarfarinDosing, and Wound Healing Strategies.

In another embodiment, a method further comprises a data server/datawarehouse storing and analyzing patient data from the at least onecommand center and providing analysis in results over a second networkto the at least one command center.

BRIEF DESCRIPTION OF THE FIGURES

FIG. 1A illustrates the logical data structure for billing, insuranceand demographic information.

FIG. 1B illustrates the logical data structure for billing, insuranceand demographic information (cont).

FIG. 2A illustrates the command center logical data structure.

FIG. 2B illustrates the command center logical data structure (cont).

FIG. 3 illustrates the logical data structure for creating a medicalhistory.

FIG. 4A illustrates the logical data structure for creating notesrelating to patient treatment and diagnosis.

FIG. 4B illustrates the logical data structure for creating notesrelating to patient treatment and diagnosis (cont).

FIG. 4C illustrates the logical data structure for creating notesrelating to patient treatment and diagnosis (cont).

FIG. 5 illustrates the logical data structure for entry of medicalorders.

FIG. 6A illustrates the logical data structure for patient care,laboratory testing and diagnostic imaging.

FIG. 6B illustrates the logical data structure for patient care,laboratory testing and diagnostic imaging (cont).

FIG. 7 illustrates the logical data structure for categories ofinformation that are permitted to be presented to intensivists and othercare givers by the system.

FIG. 8A illustrates the logical data structure for documenting patientvital signs.

FIG. 8B illustrates the logical data structure for documenting patientvital signs (cont).

FIG. 9 illustrates the distributed architecture of the presentinvention.

FIG. 10 illustrates the system architecture of the present invention.

FIG. 11 illustrates the decision support algorithm for diagnosis andtreatment of pancreatitis.

FIG. 12 illustrates the vital signs data flow.

FIG. 13A illustrates capture and display of diagnostic imaging.

FIG. 13B illustrates establishing videoconferencing in the presentinvention.

FIG. 14 illustrates the physician resources order writing data interfaceof the present invention.

FIG. 15 illustrates the physician resources database data interface ofthe present invention.

FIG. 16 illustrates the automated coding and billing system integratedwith the workflow and dataflow of the present invention.

FIG. 17 illustrates the order writing data flow of the presentinvention.

FIG. 18 illustrates the event log flow of the present invention.

FIG. 19 illustrates the smart alarms implementation of the presentinvention.

FIG. 20 illustrates the procedure note creation and line log for thepresent invention.

FIGS. 21A-B illustrate the acalculous cholecystitis decision supportalgorithm.

FIG. 22 illustrates the adrenal insufficiency decision supportalgorithm.

FIG. 23 illustrates the blunt cardiac injury decision support algorithm.

FIGS. 24A-B illustrate the candiduria decision support algorithm.

FIGS. 25A-B illustrate the cervical spine injury decision supportalgorithm.

FIGS. 26A-B illustrate the oliguria decision support algorithm.

FIGS. 26C-D illustrate the oliguria decision support algorithm (cont).

FIG. 26E illustrates the oliguria decision support algorithm (cont).

FIGS. 27A-B illustrate the open fractures decision support algorithm.

FIGS. 28A-B illustrate the pancreatitis decision support algorithm.

FIGS. 29A-B illustrate the penicillin allergy decision supportalgorithm.

FIGS. 30A-B illustrate the post-op hypertension decision supportalgorithm.

FIG. 31A illustrates the pulmonary embolism decision support algorithm.

FIG. 31B illustrates the pulmonary embolism decision support algorithm(cont).

FIG. 32 illustrates the seizure decision support algorithm.

FIGS. 33A-B illustrate the SVT determination decision support algorithm.

FIG. 33C illustrates the SVT unstable decision support algorithm.

FIGS. 34A-B illustrate the wide complex QRS Tachycardia decision supportalgorithm.

FIG. 34C illustrates the wide complex QRS Tachycardia decision supportalgorithm (cont).

FIG. 35A illustrates the assessment of sedation decision supportalgorithm.

FIG. 35B illustrates the assessment of sedation decision supportalgorithm (cont).

FIG. 36 illustrates the bolus sliding scale midazolam decision supportalgorithm.

FIG. 37 illustrates the sedation assessment algorithm decision supportalgorithm.

FIG. 38 illustrates the short term sedation process, decision supportalgorithm.

FIG. 39 illustrates the respiratory isolation decision supportalgorithm.

FIG. 40 illustrates the empiric meningitis treatment decision supportalgorithm.

FIG. 41A illustrates the ventilator weaning decision support algorithm.

FIG. 41B illustrates the ventilator weaning decision support algorithm(cont).

FIG. 42 illustrates the warfarin dosing decision support algorithm.

FIG. 43 illustrates the HIT-2 diagnostic decision support algorithm.

DEFINITIONS OF TERMS AND DATA

In the following Detailed Description of the Invention, a number ofmodules and procedures are described. For purposes of definitions, thefollowing module definitions apply and are more fully amplified in thedescriptions of the figures that follow.

Term Definitions

Following are a series of definitions for certain terms used in thisspecification:

-   Insurance carrier: This is a table of all the valid insurance    carriers listed in the system of the present invention.-   Patient guarantor: Provides the insurance guarantor information for    a given patient.-   Patient information: Provides demographic information for each    patient.-   Medical event date history: This contains the various disorders of    the patient and the dates associated with major medical events    relating to those disorders.-   Medical history: Contains non-major system medical history of a    patient.-   Drug: Contains what medication and allergies have been identified    for a patient at admission.-   Address: Contains the address or addresses for a given patient.-   Patient visit: There may be multiple records for any given patient,    since the patient may visit the ICU on more than one occasion. This    file contains a record of each visit to an ICU by a patient.-   Physician-patient task: Contains the task that had been defined for    each patient.-   Present illness: This contains a textural description of the patient    illness for the specific ICU visit.-   Physical exam: This contains the information gathered as a result of    a physical examination of the patient during the admission to the    ICU.-   Surgical fluids: This provides all the information related to the    fluids provided during surgery.-   Surgery: This contains all information pertaining to any surgical    procedure performed on a patient while the patient is at the ICU.-   Patient admit: This provides general information that needs to be    gathered when a patient is admitted into the ICU.-   Medical orders: This provides the general information for all types    of medical orders associated with a given patient.-   Daily treatment: This contains the treatment provided for a given    patient on a given day.-   Daily diagnosis: This contains the daily diagnosis for a given    patient, which includes neurological, cardiological, pulmonary,    renal, endocrinological, and any other diagnosis that may be    associated with a patient.

Vital sign information is also critical to the administration of care inthe ICU. A number of different modules collect information relating topatient vital signs. For example:

-   Patient admit: This provides the general information that needs to    be gathered when a patient is admitted to the ICU-   Patient visit: This contains a record of each visit to an ICU by a    patient.-   Patient: Provides demographic information for each patient.-   Vital sign header: This contains general information related to the    vital sign data for the particular patient.-   Vital sign: Contains the vital sign data taken at specific intervals    for a given patient.-   Hospital: This contains identifying information for a particular    hospital where the care is given.-   ICU bed: Contains the association for identifying which beds are in    a given ICU

Command center/remote location definitions and modules have also beencreated for the present invention to allow for the orderly storage andretrieval and entering of data. For example:

-   Physician-physician (such as nurses and LPN and the like): Contains    the names of all of the physicians and physician extenders for the    command center/remote location as well as for ICUs associated with    the command center/remote location.-   Communication: Contains all of the various types of communication    vehicles used to contact an individual physician or physician    extender.-   Physician role: Contains the role a physician is playing for a given    patient, (i.e., primary care, consultant, etc.)-   Patient: Provides demographic information for each patient.-   Command center/remote location: Provides identifying information for    a particular command center/remote location.-   Hospital: Contains identifying information for a particular hospital    wherein an ICU is located.-   ICU: Contains identifying information for an ICU at a hospital.-   ICU bed: Contains the association for identifying which beds are in    a given hospital.-   ICU patient location: Provides the association between an ICU and a    patient and identifies where a patient is located within an ICU in a    particular hospital.

The order entry functionality of the present invention provides acritical service for obtaining information on the patient duringadmission, medical orders, and procedures provided to the patient duringthe ICU stay. For example:

-   Radiology: Contains all radiology performed on a particular patient.-   Radiology results: Contains the results of each radiology test    performed on the particular patient.-   Drugs: Contains all relevant information for all the drugs that a    patient has been administered.-   Laboratory: Contains all laboratory tests ordered for a patient.-   Microbiology result: Contains the results of microbiology organisms    taken on a patient.-   Laboratory result: Contains the results for a laboratory test    ordered for a particular patient.

DETAILED DESCRIPTION OF THE INVENTION

The present invention is a system and method for remote monitoring ofICU's from a distant command center/remote location. By monitoring aplurality of ICU's remotely, intensivists can better spread theirexpertise over more ICU beds that heretofore achievable. The presence of24-hour a day/7 day-per-week intensivist care dramatically decreases themortality rates associated with ICU care.

Referring to FIGS. 1A and 1B, the Billing and Demographic data structureof the present invention is illustrated. Patient demographic information9010 is collected on the particular patient. This information comprisesall the typical kinds of information one would normally gather on apatient such as first name, last name, telephone number, marital status,and other types of information. Patient insurance information 9012 iscollected and associated with the patient demographic information 9010.Patient insurance information 9012 relates to information on the type ofaccident and related information such as employment, employer name,place of service, and other information that would relate to theaccident that actually occurred (if at all) and which would have to bereported to an insurance agency. This information is associated with thepatient demographic information which assigns the unique patient ID tothe particular patient.

Insurance plan information 9008 is also created and stored and comprisesinsurance carrier ID's, the plan name, policy number, and group number.This information on the insurance plan 9008 is also associated with thepatient ID and demographic information 9010.

Physician information 9002 is also created and stored for each physicianassociated with the system of the present invention. Information such asfirst and last name, credentials, and other information concerning thephysician is saved. In addition, the physician's role is identified 9004and information concerning the physician and the physician's role isassociated with the particular patient via the patient ID stored in thedemographic information 9010.

Patients are entered into the hospital by a hospital representative 9006who has a representative ID which also is ultimately associated with thepatient ID. In addition, communications data 9000 is stored concerninghow a representative can be reached (cell phone, home phone etc.).

Referring now to FIG. 1B, the Overall Billing and Insurance datastructure is illustrated. An insurance provider number 9014 is alsostored in the system. Each physician is given a provider number andprovider ID by each insurance company. Thus data must be storedregarding the ID that is given to a particular physician by eachinsurance provider. This information is also stored and can beassociated ultimately with treatment of the patient.

Each patient admitted to the hospital and to the ICU has a patient visitID associated with the patient 9017. This visit ID has patient IDinformation, ICU information, admission date, and other informationrelevant to the specific visit. This information is illustrated in FIG.1B. The visit ID 9017 is associated with the patient ID 9010 so thateach visit can be tracked by patient.

Insurance carrier information 9018 is stored by the system and isassociated with the insurance plan information 9008 as appropriate. Thusthe particular insurance carrier with its name, address, and otheridentifying information 9018 is associated with the type of plan 9008carried by the patient. The insurance carrier information 9018 togetherwith the insurance plan information 9008 is associated with the patientvia the patient ID information 9010.

Patient address information 9020 and 9022 are collected for eachindividual patient and associated with the patient demographicinformation 9010. If there is a patient guarantor, this information isobtained and stored with information on the guarantor 9026. Suchinformation as the guarantor's first and last name, date of birth, andother information is stored and is illustrated in FIG. 1B. Further, theguarantor's address 9024 is also collected and ultimately associatedwith the patient demographic information 9010.

Referring to FIGS. 2A and 2B, the Command Center logical data structureis illustrated. The various information associated with demographic andinsurance information is again used to manage the care and operations ofthe command center. Therefore, communications information 9000 iscombined with physician and physician extender (i.e. nurse, LPN and thelike) information 9002 and physician role 9004 to be associated with thedemographic information 9010. The patient visit information 9017together with this information is associated with the patient's locationwhich has a unique identifier 9030. Each location ID has patient IDinformation and visit ID information associated with it.

Referring now to FIG. 2B, the Command Center logical data structureillustration continues. Each ICU bed has an associated location ID whichcomprises hospital ICU information, room number, and bed number 9038. Inaddition, and as described earlier, instrumentation such as cameras arealso associated with the particular patient. Therefore the camerasetting 9040 will have a location ID relating to the ICU bed as well ashave camera value settings and associated camera identifier information.

Each ICU bed 9038 is associated with an ICU 9032. Each ICU hasinformation associated with it that uniquely identifies the ICU as beingassociated with the particular hospital, and having particular phonenumbers, fax numbers, work space addresses, and other information, thathelp to identify the ICU.

As noted above, each ICU is associated with a hospital 9034. Eachhospital has a unique identifier, as well as its own name, address, andother identifying information. Further, since each hospital ICU is to becoordinated through a remote command center, information on the remotecommand center 9036 is associated with the hospital information. Eachcommand center has a unique ID and has associated address informationstored as well.

Thus in the Command Center logical data structure, patient IDinformation 9010 is linked to a patient location 9030 which in turn isassociated with an ICU bed 9038 each of which beds are uniquelyassociated an ICU 9032 which is associated with a hospital 9034 which inturn has the ICU managed by a command center 9036.

An integral part of the system of the present invention is the recordingof medical history. Referring to FIG. 3, the logical relationship amongdata elements for medial history is illustrated. Patient visitinformation 9017 combined with the physician-physician extenderinformation 9002 is combined with specific note-taking information 9042.The note information comprises the date and time the notes are taken aswell as the note type. The note ID is fed information from the medicalhistory item 9044, which has its own unique medical ID associated withit. This information comprises medical text, category of information,and other information relevant to the medical history. As noted, thisinformation for medical history 9044 is associated with a note ID 9042,which in turn is associated with the patient visit and physicianinformation 9017 and 9002.

Referring to FIG. 4A, 4B, and 4C, the note-keeping logical datastructure of the present invention is illustrated. As noted earlier, thenote ID 9042 combines information from visit ID, treating physician, andother information relating to the time the note was entered. Otherinformation is associated with the note ID. Referring first to FIG. 4A,the patient visit information 9017, is associated with the note ID 9042.Various procedural information 9046 is kept by the system of the presentinvention and is associated with the visit ID 9017. Physicians are ableto create free text patient illness notations 9048 and associate themwith the note 9042. Similarly, free text information regardingfunctioning of the system 9050 is permitted and also associated withnotes regarding the particular patient and procedure 9042.

Specific notes regarding, for example, surgical procedures are alsokept. Surgery notes 9054 are associated with a particular note ID andhave such information as anesthesia, surgical diagnosis, electiveinformation, and other related surgical information. Surgical fluids9052 administered during the course of surgery are associated with thesurgery information 9054. Additionally, any surgical complications 9056are noted and also associated with the surgery which in turn has anassociated note ID.

Referring now to FIG. 4B, the logical data structure for notes and itsdescription is continued. An assessment plan 9058 is created andassociated with the same note ID for the particular patient. The planhas a free text field that allows a physician to create the appropriateassessment plan and associate it with a note ID 9042. In an embodiment,a current assessment plan for a hospitalized patient comprises sedation,analgesia, ventilation, nutrition and volume status requirements for thehospitalized patient.

Various daily notes are also kept and associated with the individualnote ID 9042. For example, the daily mental state 9060 is recorded todocument the mental state of the patient. The daily treatment 9062administered to the patient is associated with the unique note ID. Thedaily diagnosis 9068 is also created and associated with unique note ID9042.

Any unstable conditions are also noted 9070 and records kept of thoseconditions. Similarly mortality performance measures (MPM) information9072 is kept and associated with the unique note ID. To the extent thatany physical exam 9074 is administered, that physical exam and any freetext created by the physician is associated with the unique ID andrecords kept. Allergy information 9076 for the particular patient isalso created and stored along with the allergy type, and allergy name.This information is uniquely associated with the note ID. Referring nowto FIG. 4C, the Logical Data Structure for the Notes Creation andStorage description is continued. A specific note item record 9078 isalso kept and associated with unique note ID. This note item comprisesthe principal diagnosis, the chief complaint, the past history of thepatient, the reason for the note, and various other identifications andflags of information which help in documenting the patient's condition.

Any drugs that are administered to the patient, including dosage, type,and number 9086 is kept and associated with the unique note ID 9042.

Procedural note items are also documented 9082. Procedural notes involvethe procedural type, the principal diagnosis, the procedural location,procedural indications, and other information of a procedural nature.Procedural description information 9088 is kept as input to theprocedural note item. This information is also associated with aprocedural evaluation 9084 which comprises text describing theprocedural evaluation that occurred, These three items, the proceduraldescription 9088, procedural evaluation 9084, and procedural note items9082, are all uniquely associated with the note ID 9042.

Referring now to FIG. 5, the Logical Data Structure of the Medical OrderFunctionality of the Present Invention is illustrated. Each medicalorder 9092 has a unique order ID associated with it. This informationderives its uniqueness from the visit ID, the representative ID, andvarious information about the date in which the order was created andother such relevant information. Any non-drug orders 9090 are associatedwith a unique non-drug order ID. The order is classified, identified,and free text can be created by the physician to describe the order.This information in the non-drug order 9090 is associated with theunique medical order for that particular patient 9092.

Again physician and physician extender identification information 9002is also uniquely associated with the medical order to identify thephysician involved in creating the particular order in question.

Drug orders 9094 are created each with its own unique drug order ID.Various information is collected as part of the drug order including thetype of drug, the dosage, start date, frequency, stop date, to name buta few elements typical of a drug order. The drug order information 9094is associated with the unique medical order ID 9092 assigned to thatparticular patient. All of the medical order information is associatedwith patient visit information 9017 which allows that information to beuniquely identified with a particular patient for a particular visit.

Referring again to FIG. 4C, the system is also capable of annotating andstoring various log items 9080. For example, an event log item is givena number, a patient profile item has its own number, as do neurological,cardiographic, pulmonary, renal, and other events can have log itemsassociated with them and may be used as input to any of the note takingof the present invention.

Referring to FIGS. 6A and 6B, the logical data structure of the patientcare functionality of the present invention is illustrated. Each patientvisit with its unique ID 9017 has a number of other pieced ofinformation associated with it. For example, physician-patient tasks aretracked 9098 and have a unique task ID associated with them. The patientcode status 9096 is documented and associated with the physician-patienttask 9098 task ID. This information is uniquely associated with thepatient visit via the the patient visit ID 9017.

Laboratory information 9100 has a unique lab ID associated with it. Thatinformation is keyed to the visit ID and records the specimen taken, thedate it was taken, and various other information germaine to thelaboratory procedure involved. Other lab procedures 9102 are alsodocumented with another unique ID. “Other” lab ID is associated with thelaboratory ID 9100 which again is uniquely associated with theparticular patient.

Microbiological studies 9104 are documented together with the date andthe date taken and the type of study involved. Any study ofmicroorganisms 9106 is documented with a unique microorganism ID. Microsensitivities 9108 which record the sensitivity to microorganisms andcertain antibiotics is recorded and associated with the microorganism ID9106. This information in turn is associated with a microbiologicalstudy 9104, all of which is associated with the unique patient visit ID9107.

Respiratory studies 9101 are also recorded with unique identificationnumbers and a description. This information is again associated with thepatient visit ID 9017.

Referring now to FIG. 6B, the logical data structure of the patient carefunctionality of the Present Invention is further illustrated. Otherorganism studies 9118 are also conducted to determine any otherconditions associated with microorganisms that might exist with theparticular patient. This other organism information 9118 is associatedwith the microorganism studies 9106 which in turn is associated with themicrobiology category of information of the present invention 9104.

Various diagnostic imaging also takes place and is recorded. This imageinformation 9114 has unique image ID associated with each image andcomprises associated information such as the image type, the dateperformed, and other information relevant to the diagnostic imagery. Theresult of the image taken 9116 is also uniquely identified with theimage ID and a unique image result ID. This information is associatedwith the image information 9114 which again is uniquely associated withthe patient visit ID.

Various intake and output for the patient's biological functioning isrecorded 9110. Intake and output total 9112 is recorded and uniquelyassociated with the intake/output identification note 9110.Intake/output totals 9112 also comprised the weight the total taken in,the total out, and five-day cumulative totals for biological functioningof the particular patient.

Referring to FIG. 7, The Logical Data Structure Concern with ReferenceInformation for the present invention is illustrated. This datastructure allows only certain ranges of data to be input by care giversinto the system. This is accomplished by having categories ofinformation 9120 each category capable of having only certain values.Similarly, each type of data 9126 associated with each category is onlypermitted to have certain values. This combination of Category and Typeresults in a Combined ID 9122 which can be used in combination withcertain values 9128 to create a value and combination 9124 that can bepresented to a care giver viewing and entering data. This effectivelylimits errors in data entry by only allowing certain values to beentered for given types of data. For example, if only milligrams of amedication are supposed to be administered, this data structure preventsa care giver from administering kilograms of material since it is not apermitted range of data entry. The “nextkey” function 9027 is thefunction that keeps track of the ID's that are given during theadministration of the present invention. This function insures that onlyunique ID's are given and that no identical ID's are given to twodifferent patients for example.

Referring to FIG. 8A, the Logical Data Structure of the Vital SignsFunctionality of the Present Invention is illustrated. Vital sign headerinformation 9120 is created and uniquely associated with the visit IDfor the particular patient. This header information comprises adate-time stamp combined with hospital information, medical referencenumbers, and identification of the patient. Vital sign details 9122 arealso created and uniquely date-time stamped and associated with theparticular visit ID for the patient. This information comprises allmanner of vital sign information relating to blood pressure,respiration, and other factors. Vital sign information is associatedwith the patient visit 9017 and the demographic information concerningthe patient 9016. Such associations of information can be the basis forlater studies.

Referring to FIG. 8B, Additional Vital Sign Logical Data Structures areillustrated. For example, a vital sign log header 9120 is created usingthe unique hospital ID and medical record numbers. Other informationsuch a patient name, and date-time stamp are also stored. Vital sign logdetails 9124 are created and associated with the vital sign log header9120. For example, blood pressure measurements, respiration, and otherfactors are all detailed for a particular hospital ID. It should benoted that all vital sign data is logged in and kept by the systems ofthe present invention. Where vital sign information is received butcannot be associated with a particular patient, such communications arenoted as errors.

Vital sign error details 9126 are also recorded and associated with aparticular hospital. Information and the vital sign error detail alsocomprises heart rate, blood pressure, and other information. Thisinformation is associated with a vital sign error header 9130 which isassociated with the hospital identifier and the patient first and lastname and other information. Various vital sign error codes 9128 existwith the present invention and are used in association with the vitalsign error detail 9126. This information however relates tocommunications of vital sign data that are deemed “errors” as notedabove.

Care Net patient location 9132 is recorded and associated with aparticular hospital ID and location ID for the particular patient.Carenet is a proprietary product designation of Hewlett-Packard and iskept by the system of the present invention since it identifies theequipment from which measurements come. The ICU bed information 9038 isassociated with the Care Net patient location 9132.

Referring to FIG. 9, the distributed architecture of the presentinvention is shown. In concept, the distributed architecture comprises aheadquarters component 200, a command center/remote location 202, and ahospital ICU 204, which, while represented as a single hospital in thisillustration, in the preferred embodiment comprises several hospitalICUs at different locations. The headquarters unit 200 comprises adatabase server and data warehouse functionality, together with apatient information front end. The patient information front end 206provides patient specific information to the command center/remotelocation. The database server/warehouse function 208 comprises theamassed information of a wide variety of patients, in their variousconditions, treatments, outcomes, and other information of a statisticalnature that will assist clinicians and intensivists in treating patientsin the ICU. The headquarters' function also serves to allow centralizedcreation of decision support algorithms and a wide variety of othertreatment information that can be centrally managed and therebystandardized across a variety of command center/remote locations.Further, the database server/data warehousing functionality 208 servesto store information coming from command center/remote locationsreplicating that data so that, in the event of a catastrophic loss ofinformation at the command center/remote location, the information canbe duplicated at the command center/remote location once all systems areup and running.

At the hospital ICU 204, each patient room 232, 234 has a series ofbedside monitors and both video and audio monitoring of each patient inthe patient room. Each ICU further has a nurse's station with a videocamera and monitor 230 so that videoconferencing can go on between thenurses and doctors at the nursing station and those intensivists at thecommand center/remote location. The monitoring equipment at the ICU isserved by a monitor server 236, which receives and coordinates thetransmission of all bedside monitoring and nurses station communicationwith the command center/remote location. Finally, each ICU has a patientinformation front end 228, which receives and transmits to the commandcenter/remote location information concerning the identity and othercharacteristics of the patient.

Command center/remote location 202 comprises its own video capture andmonitoring capability 212 in order to allow the intensivists to view thepatients and information from the bedside monitoring as well as to havevideoconferencing with the nursing station and with patients as the needarises. Information from the monitor server 236 at the hospital ICU isserved to an HL7 (the language for transmittinghospital/patient/diagnostic data) gateway 214 to a database server 222.In this fashion, information from the bedside monitors can be stored forcurrent and historical analysis. Monitor front ends 216 and 218 allowtechnicians and command center/remote location personnel to monitor theincoming data from the patient rooms in the ICU. Information from thepatient information front end 228 is provided to an application server224, having its own patient information front end 226 for aggregatingand assembling information in the database 222 that is associated withindividual patients in the ICU.

It is expected that there will be a great deal of concurrent hospitaldata that is necessary to the implementation of the present invention.It is therefore expected that there will be a legacy database system 210having a front end 220 from which intensivists and command center/remotelocation personnel can retrieve legacy database information.

Referring to FIG. 10, a system architecture of one embodiment of thepresent invention is illustrated. Headquarters 200 comprises anapplication server 238, an NT file server 240, and Sun SPARC Enterprise250242 and Enterprise network management system 244, a Cisco 3600 router246, a Cisco 2924 switch 248, and a hot phone 250. The applicationserver 238 is designed to monitor and update those applications used atthe command center/remote location. The NT file server serves tomonitor, store, and replicate information coming from the commandcenter/remote locations. The SPARC Enterprise 250 server 242 is a discstorage server, for storing and serving information, such as practiceguidelines, algorithms, patient information, and all matter of otherinformation records that must be stored in order to support the presentinvention. As explained below, the SPARC Enterprise 250 server and othercomponents are such as routers and switches are commonly used in theICU, the command center/remote location, and the headquarters. Forexample:

-   -   The Cisco 3600 router is a multi-function device that combines        dial access, routing, and local area network (LAN) to LAN        services, as well as the multi-service integration of voice,        video, and data in the same device. This is necessary, since the        various command center/remote locations, headquarters, and        intensive care units all must integrate and transmit video,        audio, and data among the various entities.    -   The Cisco 7204 is a router which provides high speed LAN        interconnect, virtual private networks, and Internet access, all        of which is required for providing the communication in the        network of the present invention; and    -   The Cisco 2924 switch is an autosensing fast ethernet switch,        allowing networked multimedia and virtual LAN support.        Multi-level security is also offered in the switch to prevent        unauthorized users from gaining access and altering switch        configuration. These components are also identified in the        figures (below).

The particular commercial systems named here are given as but someexamples of equipment available today. The function of these equipmentis the important factor. Other similar or improved equipment can also beutilized.

The network management system 244 allows the entire traffic andcondition of the network to be monitored and to allow maintenance totake place. The router 246 and switch 248 is used for communication withthe various command center/remote locations that are served by theHeadquarters component. The Headquarters component interacts via framerelay with the command center/remote location 202.

Command center/remote location 202 comprises an applications server 262for the purpose of running various applications for the intensivists andcommand center/remote location staff. The NT file server 264 at thecommand center/remote location allows patient files, historical files,algorithms, practice standards, and guidelines, to be served to theclinicians and intensivists to assist in monitoring the patients. TheSun SPARC Enterprise 250266 is used to for storage purposes as notedabove. The Enterprise network management system 268 monitors the overallhealth of the network of command center/remote locations and intensivecare units as well as the functionality of the individual pieces ofequipment within the command center/remote location. A Cisco 2924 switch256 and Cisco 7204 router 258, combined with the Cisco 3600 router 260allows for point to point communication over a T1 line, with a pluralityof intensive care units located remotely from the command center/remotelocation. Hot phones 252 and 254 allow communication with theheadquarters and the intensive care unit.

Intensive care unit 204 comprises a Cisco 2924 switch 272 for thepurpose of interfacing with the various audio-video feeds 274, 276 fromthe various patient rooms and the nursing station. A local work station280 is connected to a scanner 282 which allows data to be input,scanned, and communicated via the point to point T1 communications tothe command center/remote location. Further, the workstation 280provides for textual advice and patient orders to be delivered to theintensive care unit for execution. The intensive care unit alsocomprises a laser printer 284 for the printing of patient orders andother information relevant to the care of intensive care patients.Referring to FIG. 11, the videoconferencing/surveillance/imagingcomponents of the present invention are illustrated. The hospital ICU204 comprises a series of video cameras 290, which are located inpatient rooms and at the nurse's station. Control for the cameras isprovided through an RS424 to RS232 converter 288, with instructions forimaging emanating from the workstation at the command center/remotelocation 252 through the ICU workstation 280 through a multi-port serialcontroller 286. Video feed from the video cameras 290 is provided to anaudio-video switcher 292, which in turn provides its output to themulti-port serial controller 286 for subsequent viewing at the nurse'sstation and at the command center/remote location. Of equal importanceis a microphone feed from the patient and from the nurses. Thatmicrophone 296 provides its signal to an audio line amplifier 294, whichin turn provides an audio feed to the audio-video switcher 292. In thisway, a patient can provide information, as can nurses who are visitingthe patient during the course of patient care. It is also important thatinformation of an audio nature be fed to the intensive care unit, bothto the patient rooms and to the nurse's station. To do this, themulti-port serial controller 286 provides an audio signal to a reverseaudio switcher 298, which in turn provides information to speakers 300that are located at the nurse's station as well as at the bedside of thepatients. Information to the reverse audio switcher is provided an audioamplifier 302 from information from a video code 304, which in turn isconnected to the workstation at the ICU. As noted earlier, a scanner 282is provided, so that information can be scanned and provided to thecommand center/remote location 202 and a hot telephone 278 communicateswith a telephone 252 at the command center/remote location.

Referring to FIG. 12 the vital signs data flow is illustrated. Themonitoring system at each ICU bedside comprises a monitoring system formonitoring the vital signs for the patient. The vital sign monitoringsystem 450 captures vital sign data 452 and transmits that vital signdata 454 using the HL7 language (the standard processing language forhospital data and information). The processor at the ICU processes thevital sign data for transmission and storage purposes and transmits thatinformation to the remote location. Vital sign data is then loaded intothe data base 458. The data base for each individual patient is thenreviewed and process rules are applied 460 to the vital sign data. Theseprocess rules relate to certain alarming conditions which, if a certainthreshold is reached, provides an alarm to the intensivist on duty. Thevital sign alarm 462 is then displaced to the intensivist who can thentake appropriate action. A typical type of rule processing of the vitalsign data might be if blood pressure remains at a certain low level foran extended period of time, or if heart rate remains high for anextended period of time. In addition a wide range of other rules areprovided which will provide an audible alarm to the intensivist before acritical situation is reached.

In addition to the information being provided to the alarming system forthe intensivist, the vital sign data 464 is also transmitted 466 into adatabase warehouse 468 comprising vital sign data 470 from not only theindividual patient but from all of the patients being cared for, in theICU. This database warehouse provides the ability to do data mining fortrends that can give rise to additional process rules and vital signthresholding. In addition to the transmission of vital sign data 454 tothe remote site, the vital sign data is displayed in real time at theICU 472. In an embodiment, the patient data elements are displayed atthe ICU and/or the remote command center according to an organ systemassociated with the patient data element. In yet another embodiment, analert comprises displaying the hospitalized patient's name in a colorindicative of the severity of the alert.

Referring to FIG. 13A the diagnostic imaging interaction is illustrated.X-rays for example, are created and transmitted to the command center472. Additionally, the information could be ACT scan, MRI, or any othermethod of medical diagnostic imaging. The x-ray image is captured at thecommand center 474 where it is stored and in addition displayed on theimage monitor 476 for the intensivist to review.

Referring to FIG. 13B the interactive video session is illustrated. Avideo conferencing session is established 478 regarding a particularpatient in an ICU bed. Using the video cameras in each room and/or atthe nurses station at the ICU, the patient and/or the nurse can beviewed 480. On the other end of the video conferencing session is theintensivist who can then both visually and orally communicate with thepatient and/or nurse 482.

Referring to FIG. 14 the physician resources and order writing datainterface is illustrated. The user interface 484 allows the physiciansto access physician resources 486. These resources provide guidelinesfor the treatment of the critically ill. In this example the intensivistis requested to enter the antibiotic associated with colitis 488. Thesystem then generates a request for a fecal leukocyte test 490. Thisrequest is translated into an order writing module 496 which results inthe actual order for the test 502. Since the order needs to betransmitted to the appropriate organization for execution, anappropriate order is generated to the microbiology laboratory 500 inthis instance. The order results are then achieved 506 and thecompletion of the order is reported to the order writing assignmentmanager 496. In addition, the order writing module 502 also results in atask list 504 of orders for various other individuals in laboratories.In addition, user interface 484 allows the physician to re-enter thephysician resources module at any particular location with results ofthe tests. These tests are then fed into the system to continue with thediagnostic algorithm processing of the patient test results 494. Theuser interface also allows interaction with the resident database 498.

Referring to FIG. 15 the physician resources database data interface isillustrated. User interface 508 allows the intensivist to interact withthe physician resources data base 510. In this example, resident database 524 which comprises the identification and background of theresident admitting the patient causes an admission diagnosis 526 to becreated. In this example a diagnosis of pancreatitis is illustrated.This diagnosis of pancreatitis 522 alerts the physician resources module510 which causes an entry for the topic pancreatitis 512. The diagnosisalgorithm for pancreatitis 514 is then retrieved and a request for anApache II score 516 is requested. The system also requests informationfor operative data 528 describing what if any operations have takenplace with respect to this patient, vital sign data 530, request forlaboratory information 532, past medical history for the patient 534 andpatient demographics 536. All this information is provided to the ApacheII score assignment manager 538 which assigns an Apache II score basedupon weighted composite up to twenty five different variables. ThisApache II score is provided to the Apache II score request module 516.If the severity based Apache II score is greater than or equal to eightthe diagnostic of the system continue 520. If the Apache II score isless than eight, the patient is triaged to a none ICU bed 518 since thepatient will not necessarily require intensive care thereby savingrelatively scarce resources of the ICU for those who are trulycritically ill.

Referring to FIG. 16 the automated coding/billing work flow and dataflow is illustrated. Clearly ICUs must be paid for the care that theygive. At the outset of the visit 540 the user interface 542 allows forthe input of International Classification of Diseases, Ninth Revision(ICD 9) diagnosis code information concerning complexity of the case,whether the patient is stable, whether the physician involved is theattending physician or consulting physician and all other manner ofinformation required for billing purposes. In addition, resident data544 is input such as patient demographics, insurance information,physician, guarantor, the date that the service is provided. All thisinformation is provided to the data manager 546 which assembles therequired data element for subsequent processing. The data manager sendsthe demographic, physician, guarantor, insurance and related informationto a bill generator 548 which begins to assemble of the information tosubsequently generate a bill. Clinical information is provided to thecurrent procedural terminology (CPT) code assignment manager whichassigns codes based upon the scores and user input for bill generationpurposes. A history of present illness (HPI) score 560 is generatedalong with a review of systems (ROS) score 562. A past, family, and/orsocial history (PFSH) score 564 is generated along with a score relatingto the physical exam 566. A mortality prediction model (MPM) score 568which is a score relating to the severity of the illness is alsogenerated. All of these various scores are provided to the CPTassignment manager 558. Periodically information is downloaded formanagement reports 556. Once all of the information for the CPT codeassignment is generated that information is provided to the billgenerator 548 which assembles all the data elements needed to generate aHealth Care Financing Administration (HCFA) 1500 claim form. The inputfor the bill generator is then verified 550 where the physician candisagree with code assignments return progress notes and generallyreview the bill. This smart processing of the HCFA 1500 claim formallows for fewer mistakes to be made. If there is any error oradditional information that is required, the verification process failsthe proposed claim form and information regarding that failure isprovided back to the resident data for completion of any missing items.Once an invoice has been verified as having the appropriate informationto be submitted the HCFA 1500 claim form is generated 554. Additionalinformation is written to a billing data file 552 for importation to thepatient accounting system of the present invention.

Referring to FIG. 17 the order writing data flow is illustrated. Orderentry user interface 600 allows the intensivist to order procedures andmedication to assist the patients in the ICU. For example, theintensivist can order an ECG 604. Thereafter the order is reviewed and adigital signature relating to the intensivist is supplied 606. Oncereviewed and signed off, the order is approved 607 and sent to the dataoutput system 610. Thereafter the data output system prints the order tothe printer in the ICU 616. For record keeping purposes the order isexported in the HL7 language to the hospital data system 618. Inaddition the data output system adds an item to the data base that willsubsequently cause an intensivist to check the ECG results. Thisnotification to the task list is provided to the database 614. Inaddition, as part of the database an orders file relating to thespecific patient is also kept. The fact that and ECG has been ordered isentered in the orders file for that patient.

In a similar fashion using the order entry user interface 600 theintensivist can order medications 602 for a patient. The medicationorder then is provided to an order checking system 608. The orderchecking system retrieves information from the database 614 relating toallergies of the patient and medication list which includes medicationswhich are already being administered to the patient. This allows for theorder checking system to check for drug interactions. Further laboratorydata is extracted from the database 614 and the order checking systemchecks to insure that there will be no adverse impact of the recommendeddosage upon the renal function of the patient. Once the order checkingsystem 608 is completed, the order is okayed and provided to the orderreview and signature module 606. In this module the digital signature ofthe intensivist is affixed to the order electronically and the order isapproved 607. Thereafter it is provided to the data output system 610where again the orders are printed for ICU and 616 and for the hospitaldata system. In this case, any medications that are ordered are thenprovided to the medications list file in the database 614 so that thecomplete list of all medications that are being administered to the ICUpatient is current.

Referring to FIG. 18 the event log is illustrated. The database 620contains all manner of notes and data relating to the particular patientthat is admitted to the ICU. For example, admission notes 622 are takenupon admission of the patient and stored in the file that is specific tothat patient. Progress notes 624 are created during the patients staywithin the ICU to note the progress the patient is making giving thevarious treatments. Procedural notes 626 are also created by theintensivist to note what procedures have taken place and what if anyevents have occurred associated with those procedures. Laboratory datasuch as positive blood cultures are also stored in the file 628 in thedatabase 620. Further x-ray data 630 and abnormal CT Scan results arestored in the database.

The result of these individual files are then provided to an event logmanager 632. For example, admission notes might contain operationsperformed. Progress notes 624 might relate to the operations preformed.This information is provided to the event log manager 632. Admissioninformation is also input to the event log manager as are a listing ofthe procedures administered to the patient. To the extent there arepositive blood cultures in the laboratory data 628 those are provided tothe event log manager 632 as are abnormal CT scan results. All of thisinformation is made available through the user interface 634. Thus theevent log presents in a single location key clinical information fromthroughout a patients stay in the ICU. The event log user interfaceprovides caregivers with a snapshot view of all salient events sinceadmission. All relevant data on procedures and laboratory tests, etc.are presented chronologically.

Referring to FIG. 19 the smart alarms of the present invention areillustrated. The smart alarm system constantly monitors physiologic data(collected once per minute from the bedside monitors) and all otherclinical information stored in the database (labs, medications, etc).The periodicity of the collection of data is stated for illustrativepurposes only. It is well within the scope of the present invention tocollect physiological data at more frequent time intervals. Thus,monitor 636 provides information in HL7 form to the interface engine638. The physiological data is then formatted by the interface enginefor storage in the database 640 where all patient information ismaintained. The rules engine 642 searches for patterns of dataindicative of clinical deterioration.

One family of alarms looks for changes in vital signs over time, usingpre-configured thresholds. These thresholds are patient-specific andsetting/disease-specific. For example, patients with coronary arterydisease can develop myocardial ischemia with relatively minor increasesin heart rate. Heart rate thresholds for patients with active ischemia(e.g. those with unstable angina in a coronary care unit) are set todetect an absolute heart rate of 75 beats per minute. In contrast,patients with known coronary artery disease in a surgical ICU havealarms set to detect either an absolute heart rate of 95 beats perminute or a 20% increase in heart rate over the baseline. For thisalarm, current heart rate, calculated each minute based on the medianvalue over the preceding 5 minutes, is compared each minute to thebaseline value (the median value over the preceding 4 hours).Physiologic alarms can be based on multiple variables. For example, onealarm looks for a simultaneous increase in heart rate of 25% and adecrease in blood pressure of 20%, occurring over a time interval of 2hours. For this alarm, thresholds were initially selected based on theknown association between changes in these two variables and adverseclinical events. Actual patient data were then evaluated to determinethe magnitude of change in each variable that yielded the best balancebetween sensitivity and specificity. This process was used to set thefinal thresholds for the rules engine.

Alarms also track additional clinical data in the patient database. Onealarm tracks central venous pressure and urine output, becausesimultaneous decreases in these two variables can indicate that apatient is developing hypovolemia. Other rules follow laboratory data(e.g. looking for need to exclude active bleeding and possibly toadminister blood).

The purpose of the rules engine is to facilitate detection of impendingproblems and to automate problem detection thereby allowing forintervention before a condition reaches a crisis state.

Referring to FIG. 20 the procedural note-line log is illustrated. Thislog allows clinicians to evaluate the likelihood that a given proceduremight result in further complications. In this example presented in thisFIG. 20 a catheter removal is illustrated. When a new catheter isinserted in a patient 648 a procedural note is created on the procedurenote creation user interface 646. The note is reviewed and a digitalsignature is attached to the note to associate the note with aparticular intensivist 654. The procedure is then approved and isprovided to the data output system 656. The procedural note is thenprinted on the printer in the ICU 658 and is exported in HL7 language tothe hospital data system 660. In addition, this also triggers a billingevent and the data output system provides appropriate output to thebilling module 662 to generate an invoice line item. In addition, thenote is stored in the emergency medical record associated with thepatient in the database 664. In addition, the line log is updated in thedatabase 664 to show what procedure was administrated to a patient atwhat time. If there is an existing catheter, that is displayed to theintensivist at the procedure note creation user interface 646. Thiswould show an existing catheter changed over a wire 650. Thatinformation is provided to the line id module 652 which extractsinformation from the line log in the database 664. This informationresults in a note being created and provided to the note review andsignature module 664. Thus the line log contains, for each patient,relevant information about all in-dwelling catheters, including type andlocation of the catheter, insertion date, the most recent date that thecatheter was changed over a wire, and the date the catheter was removed.This information helps clinicians evaluate the likelihood that a givencatheter is infected and guides its subsequent management of thatprocedure.

Evidence-based Guidelines, Algorithms, and Practice Standards DecisionSupport Algorithms

In order to standardize treatment across ICUs at the highest possiblelevel, decision support algorithms are used in the present invention.These include textural material describing the topic, scientifictreatments and possible complications. This information is available inreal time to assist in all types of clinical decisions from diagnosis totreatment to triage.

All connections among components of the present invention are presentlywith a high bandwidth T-1 line although this is not meant as alimitation. It is anticipated that other existing and future highbandwidth communication capabilities, both wired and wireless, as wellas satellite communications will be suitable for the communicationsanticipated for the present invention.

As noted earlier, a key objective of the present invention is tostandardize care and treatment across ICUs. This is effective in thepresent invention by providing decision support to intensivists as wellas information concerning the latest care and practice standards for anygiven condition. As noted in Table I below, a wide variety of conditionsis noted. Each of the conditions has an associated guideline of practicestandard that can be presented to the intensivist who might be facedwith that particular condition in a patient. These guidelines ofpractice standards can be accessed at the command center/remote locationor at the ICU to assist in the treatment of the patient. Thus, thegeneral categories of cardiovascular, endocrinology, general,gastrointestinal, hematology, infectious diseases, neurology,pharmacology, pulmonary, renal, surgery, toxicology, trauma all haveguidelines and practice standards associated with them.

TABLE 1 EVIDENCE-BASED GUIDELINES ALGORITHMS & PRACTICE STANDARDSDECISION SUPPORT CARDIOVASCULAR BRADY ARRHYTHMIAS CARDIOGENIC SHOCKCARDIO-PULMONARY RESUSCITATION GUIDELINES CONGESTIVE HEART FAILUREEMERGENCY CARDIAC PACING FLUID RESUSCITATION HYPERTENSIVE CRISISIMPLANTABLE CARDIO-DEFIBRILLATORS INTRA-AORTIC BALLOON DEVICES MAGNESIUMADMINISTRATION IN PATIENTS MANAGEMENT OF HYPOTENSION, INOTROPESMYOCARDIAL INFARCTION MI WITH LEFT BUNDLE BRANCH BLOCK PA CATHETERGUIDELINES & TROUBLE-SHOOTING PERMANENT PACEMAKERS & INDICATIONSPULMONARY EMBOLISM DIAGNOSIS PULMONARY EMBOLISM TREATMENTSUPRA-VENTRICULAR TACHYARRHYTHMIAS UNSTABLE ANGINA VENOUSTHROMBOEMBOLISM PROPHYLAXIS VENOUS THROMBOSIS: DIAGNOSIS & TREATMENTVENTRICULAR ARRHYTHMIAS ENDOCRINOLOGY ADRENAL INSUFFICIENCY DIABETICKETOACIDOSIS HYPERCALCEMIA: DIAGNOSIS & TREATMENT HYPERGLYCEMIA: INSULINTREATMENT STEROID REPLACEMENT STRATEGIES THYROID DISEASE GENERAL DEALINGWITH DIFFICULT PATIENTS AND FAMILIES END OF LIFE DECISIONS ETHICALGUIDELINES PRESSURE ULCERS ORGAN PROCUREMENT GUIDELINES GASTROINTESTINALANTIBIOTIC ASSOCIATED COLITIS HEPATIC ENCEPHALOPATHY HEPATIC FAILUREMANAGEMENT OF PATIENTS WITH ASCITES NUTRITIONAL MANAGEMENT ACUTEPANCREATITIS UPPER GI BLEEDING: STRESS PROPHYLAXIS UPPER GI BLEEDING:NON-VARICEAL UPPER GI BLEEDING: VARICEAL HEMATOLOGY HEPARINHEPARIN-INDUCED THROMBOCYTOPENIA THE BLEEDING PATIENT THROMBOCYTOPENIATHROMBOLYTIC THERAPY TRANSFUSION GUIDELINES USE OF HEMATOPOETIC GROWTHFACTORS WARFARIN INFECTIOUS DISEASES ACALCULUS CHOLECYSTITISANTIBIOGRAMS BLOODSTREAM INFECTIONS CANDIDURIA CATHETER RELATEDSEPTICEMIA CATHETER REPLACEMENT STRATEGIES ENDOCARDITIS PROPHYLAXISENDOCARDITIS DIAGNOSIS AND TREATMENT FEBRILE NEUTROPENIA FUO HIV +PATIENT INFECTIONS MENINGITIS NECROTIZING SOFT TISSUE INFECTIONSNON-INFECTIOUS CAUSES OF FEVER OPHTHALMIC INFECTIONS PNEUMONIA,COMMUNITY ACQUIRED PNEUMONIA, HOSPITAL ACQUIRED SEPTIC SHOCK SINUSITISSIRS TRANSPLANT INFECTION PROPHYLAXIS TRANSPLANT-RELATED INFECTIONSNEUROLOGY AGITATION, ANXIETY, DEPRESSION & WITHDRAWAL BRAIN DEATHGUILLAIN-BARRE SYNDROME INTRACEREBRAL HEMORRHAGE MYASTHENIA GRAVISNEUROMUSCULAR COMPLICATIONS OF CRITICAL ILLNESS NON-TRAUMATIC COMASEDATION STATUS EPILEPTICUS STROKE SUB-ARACHNOID HEMORRHAGE PHARMACOLOGYAMINOGLYCOSIDE DOSING AND THERAPEUTIC MONITORING AMPHOTERICIN-BTREATMENT GUIDELINES ANALGESIA ANTIBIOTIC CLASSIFICATION & COSTS DRUGCHANGES WITH RENAL DYSFUNCTION PENICILLIN ALLERGY NEUROMUSCULAR BLOCKERSVANCOMYCIN THERAPEUTIC DRUG MONITORING PULMONARY ARDS: HEMODYNAMICMANAGEMENT ARDS: STEROID USE ARDS: VENTILATOR STRATEGIES ASTHMABRONCHODILATOR USE IN VENTILATOR PATIENTS BRONCHOSCOPY & THORACENTESISGUIDELINES COPD EXACERBATION & TREATMENT CXR (INDICATIONS) NONINVASIVEMODES OF VENTILATION ENDOTRACHEAL TUBES & TRACHEOTOMY TREATMENT OFAIRWAY OBSTRUCTION VENTILATOR WEANING PROTOCOL RENAL ACUTE RENALFAILURE: DIAGNOSIS ACUTE RENAL FAILURE: MANAGEMENT & TREATMENT DIALYSISDIURETIC USE HYPERKALEMIA: ETIOLOGY & TREATMENT HYPERNATREMIA: ETIOLOGY& TREATMENT HYPOKALEMIA: ETIOLOGY & TREATMENT HYPONATREMIA: ETIOLOGY &TREATMENT OLIGIURIA SURGERY OBSTETRICAL COMPLICATIONS DISSECTING AORTICANEURYSM POST-OPERATIVE HYPERTENSION POST-OPERATIVE MYOCARDIAL ISCHEMIA(NON-CARDIAC ARRHYTHMIAS AFTER CARDIAC SURGERY POST-OPERATIVE BLEEDINGPOST-OPERATIVE MANAGEMENT OF ABDOMINAL POST-OPERATIVE MANAGEMENT OF OPENHEART POST-OPERATIVE MANAGEMENT OF THORACOTOMY POST-OPERATIVE POWERWEANING POST-OPERATIVE MANAGEMENT OF CAROTID WOUND HEALING STRATEGIESTOXICOLOGY ACETAMINOPHEN OVERDOSE ANAPHYLAXIS COCAINE TOXICITY ALCOHOLWITHDRAWAL HYPERTHERMIA LATEX ALLERGY UNKNOWN POISONING TRAUMA ABDOMINALCOMPARTMENT SYNDROME BLUNT ABDOMINAL INJURY BLUNT AORTIC INJURY BLUNTCARDIAC INJURY DVT PROPHYLAXIS EXTREMITY COMPARTMENT SYNDROME HEADINJURY HYPOTHERMIA IDENTIFICATION OF CERVICAL CORD INJURY SPINAL CORDINJURY OPEN FRACTURES PENETRATING ABDOMINAL INJURY PENETRATING CHESTINJURY

Referring to FIGS. 21A-B, the acalculous cholecystitis decision supportalgorithm of the present invention is illustrated. If an intensivistsuspects that acalculous cholecystitis may be present, the intensivistmay not be certain of all of the aspects that would be indicative ofthis particular condition. Therefore, the intensivist is lead through adecision support algorithm, which first causes the intensivist todetermine if the patient is clinically infected, either febrile orleukocystosis 800. If this criterion is not met, the intensivist isprompted that it is unlikely that the patient has acalculouscholecystitis 802.

If the patient is clinically infected 800, the intensivist is promptedto determine whether the patient has had a previous cholesystectomy 804.If patient has had a previous cholesystectomy, the intensivist isprompted that it is very unlikely that the patient has acalculouscholecystitis 806. Alternatively, if a patient has not had a previouscholesystectomy, the intensivist is prompted to determine whether thepatient has any of seven (7) risk factors, specifically: 1) Prolongedintensive care unit (ICU) stay (defined as greater than six (6) days);2) recent surgery (particularly aortic cross clamp procedures); 3)hypotension; 4) positive end-expiratory pressure (PEEP) greater than ten(10) centimeters (cm); 5) transfusion greater than six (6) units ofblood; 6) inability to use the gastrointestinal (GI) tract fornutrition; or 7) immunosuppresssion (AIDS, transplantation, or leukemia)808. If the patient has none of these seven risk factors, theintensivist is prompted that the patient probably does not haveacalculous cholecystitis 810.

If the patient has any of the seven risk factors 808, the intensivist isprompted to determine whether the patient has any of the followingsymptoms: right upper quadrant (RUQ) tenderness; elevatedalkalinephosphatase; elevated bilirubin; or elevated liverttransaminases 812. If the patient has none of these four (4) symptoms812, the intensivist is prompted to consider other more likely sourcesof infection (see fever of unknown origin or FUO) 814. If the infectionremains undiagnosed following an alternative work-up, the intensivist isprompted to re-enter the algorithm 814.

If the patient has any of these four (4) symptoms 812, the intensivistis prompted to determine whether alternative intra-abdominal infectioussources are more likely 816. If alternative intra-abdominal infectioussources are not more likely, the intensivist is prompted to determinewhether the patient is sufficiently stable to go for a test 826. If thepatient is sufficiently stable to go for a test, the intensivist isprompted to perform an mso4 Cholescintigraphy 836. The normal AC isexcluded 838. If the test indicates an abnormality, the intensivist isprompted to consider a cholecystectomy or precutaneous drainage 840. Ifthe patient is not sufficiently stable to go for a test, the intensivistis prompted to perform a bedside ultrasound 828. If no other infectiousetiologies are identified and no abnormalities of the gall-bladder arenoted but: a) the patient remains ill 830, the intensivist is promptedto consider empiric cholecystostomy 832. If no other infectiousetiologies are identified and no abnormalities of the gall bladder arenoted but: b) the patient is improving 830, the intensivist is promptedto continue to observe the patient 834.

If alternative intra-abdominal infectious sources are more likely 816,the intensivist is prompted to determine whether the patient issufficiently stable to go for a test 818. If the patient is sufficientlystable to go for a test 818, the intensivist is prompted to perform anabdominal CT scan 820. If no other infectious etiologies are apparentand the test: a) demonstrates abnormalities of the gall-bladder but notdiagnostic; or b) no gall-bladder abnormalities are noted 822, theintensivist is prompted to maintain continued observation of the patient824. Alternatively, if neither of these criteria is met 822, theintensivist is prompted to perform an mso4 cholescintigraphy 836. NormalAC is excluded 838. If the test is abnormal, the intensivist is promptedto consider cholecystectomy or precutaneous drainage 840. If the patientis not sufficiently stable to go for a test, the intensivist is promptedto perform a bedside ultrasound 828. If no other infectious etiologiesare identified and no abnormalities of the gall-bladder are noted but:a) the patient remains ill 830, the intensivist is prompted to considerempiric cholecystostomy 832. If no other infectious etiologies areidentified and no abnormalities of the gall bladder are noted but: b)the patient is improving 830, the intensivist is prompted to continue toobserve the patient 834.

Referring to FIG. 22, the adrenal insufficiency decision supportalgorithm of the present invention is illustrated. When an intensivistsuspects an adrenal problem may be presented in a patient, theintensivist may initiate the adrenal insufficiency decision supportalgorithm which prompts questions concerning all aspects of thecondition. First the intensivist is prompted to determine whether thepatient is either hypotensive and/or has been administered pressors forforty-eight hours or longer 900. If neither condition is met, the systemadvises the intensivist that it is unlikely that an adrenal problem ispresent 902.

If one or both conditions are met, the intensivist is asked whether anobvious cause for hypotensive blood pressure or treatment with pressorsare manifested, such as hypovolemia or low blood volume, myocardialdysfunction, or spinal injury 904. If at least one of these obviouscauses is present, the intensivist is alerted by the system that theunderlying cause must first be treated 906. If treatment of a suspectedunderlying cause is reversed, yet the hypotension or pressor needpersists, the intensivist is further directed to determine whether otheradrenal problems have occurred in the patient's history 908, 910, 912.

In order to examine prior treatment issues, the intensivist is firstprompted by the system to determine if the patient has been treated withsteroids in the previous six months for at least a two week period 908.Next, the intensivist is prompted to determine whether the patient hashyponatremia or hyperkalemia 910. The intensivist is also prompted todetermine whether the patient has experienced anticoagulation or becomecoagulopathic prior to the hypotension or pressor treatment 912.According to the responses provided by the intensivist to the systemqueries or blocks 908, 910, and 912, the system calculates a treatmentaction 914 as follows: The array of possible responses to diagnosisquestions 908, 910, and 912 are given a Decision Code as shown in Table1A: Adrenal Insufficiency Considerations, below.

TABLE 1A Adrenal Insufficiency Considerations Question 1 Question 2Question 3 908 910 912 Decision Code N N N A N N Y A N Y N B N Y Y C Y YY C Y N N D Y Y N B Y N Y D Y Y Y C

The possible decision codes of Table 1A are as follows:

Decision Code Treatment Action A Do cosyntropin stim test B Considerpossible Adrenal Insufficiency. Give decadron 5 mg IV, so cosyntropinstim test and empirically treat with hydro- cortione 50 mg IV every 8hours until stim test results return. C Consider possible AdrenalInsufficiency, secondary to adrenal hemorrhage. Give decadron 5 mg IV,so cosyntropin stim test and empirically treat with hydrocortione 50 mgIV every 8 hours until stim test results return. D Do cosyntropin stimtest, may empirically treat with hydro- cortisone 25-50 mg IV every 8hours until stim test results return

Besides specialized treatment actions listed in the decision codesabove, the intensivist is directed to administer a cosyntropinstimulation test 914 in order to see how much cortisone the adrenalgland is producing.

After performing the cosyntropin stimulation test, the intensivist isprompted to enter the patient's level of cortisol before administeringcosyntropin and thirty minutes afterwards 916. The software analyzes thetest results as follows: The results in Table 2, shown below, are shownas having certain decision codes A through F.

TABLE 2 Cosyntropin Stimulation Test Results basal (A) basal (B) basal(C) <15 15-20 >25 stim (D) stim (E) stim (F)  <5  5-10 >10

Depending upon the outcome of the analysis of Table 2, one of thetreatment actions, shown below in Table 3, will be displayed 918.

TABLE 3 Cosyntropin Test Result Treatment Actions Decision CodeTreatment Action A + D Adrenal insufficiency diagnosed - treat withhydrocortisone 50 mg IV every 8 hours and consider endocrine consult A +E Probable Adrenal insufficiency- treat with hydrocortisone B + D 25-50mg IV every 8 hours and taper as intercurrent illness improves A + FPossible Adrenal insufficiency- consider treatment with B + Ehydrocortisone 25 mg IV every 8 hours and taper as intercurrent illnessimproves A + F Adrenal insufficiency unlikely- would not treat B + F C +E C + F

Referring to FIG. 23, the blunt cardiac injury decision supportalgorithm of the present invention is illustrated. If an intensivistsuspects that blunt cardiac injury may be present, the intensivist maynot be certain of all aspects that would be critical to or indicative ofthis particular condition. Therefore, the intensivist is lead through adecision support algorithm, which first causes the intensivist todetermine whether any of seven (7) risk factors are present: 1) wasthoracic impact greater than fifteen (15) mph; 2) was the steering wheeldeformed; 3) was there precordial ecchymosis, contusions, or abrasions;4) was marked precordial tenderness present; 5) was there a fracturedsternum; 6) were bilateral rib/costal cartilage fractures present; 7)were thoracic spine fractures present 1000. If none of the 7 riskfactors are present, the intensivist is prompted that no furtherevaluation is necessary 1002. If any of the 7 risk factors are present,the intensivist is prompted to obtain an electrocardiogram (ECG) andchest X-ray (CXR) 1004.

Once the results of the ECG and CXR are obtained, the intensivist isprompted to determine: whether the ECG results are abnormal, withabnormal being defined as anything other than sinus rhythm, includingectopy and unexplained sinus tachycardia (greater than 100beats/minute); and whether the CXR results are abnormal, with abnormalbeing defined as any skeletal or pulmonary injury, especially cardiacenlargement 1006. If either the ECG or CXR is not abnormal, theintensivist is prompted that a monitored bed is unnecessary for thepatient 1008. If either the ECG or CXR is abnormal, the intensivist isprompted to determine whether there is any hemodynamic instability(hemodynamic instability being defined as the absence of hypovolemia,spinal cord injury, or sepsis) that cannot be explained by hypovolemia,spinal cord injury, or sepsis 1010.

If this criterion is not met, the intensivist is prompted: that thepatient should be in a monitored bed; that the ECG should be repeated at24 hours; that, at any time, if unexplained hemodynamic instability ispresent, the intensivist should request a stat echo; and that, if bluntthoracic aortic injury is also suspected, a transesophogealechocardiogram (TEE) is favored over a transthoracic echocardiogram(TTE) 1012. Once the results of these tests are obtained, theintensivist is prompted further to determine whether ectopy, arrhythmia,or abnormality is present on the ECG 1014. If none of these criteria aremet, the intensivist is prompted that cardiac injury is excluded 1016.If any of these criteria are met, the intensivist is prompted that heshould consider monitoring the patient for an additional 24 hours 1018.

If the internist determines that there is any hemodynamic instabilitythat cannot be explained by hypovolemia, spinal cord injury, or sepsis1010, he is prompted: to perform a stat echo; and, if blunt thoracicaortic injury is also suspected, that a transesophogeal echocardiogram(TEE) is favored over a transthoracic echocardiogram (TTE) 1020. Oncethe results of the stat echo are obtained, the intensivist is promptedto determine whether the echo is abnormal with possible causes for theabnormality being: pericardial effusion (tamponade; hypokineses orakinesis (wall motion); dilatation or reduced systolic function; acutevalvular dysfunction; and/or chamber rupture 1022. If the stat echo isabnormal, the intensivist is prompted to treat as indicated for theparticular cause of the abnormality 1026. If the stat echo is notabnormal, the intensivist is prompted to continue to monitor the patientand repeat the ECG at 24 hours 1024.

Once the results of the ECG are obtained, the intensivist is prompted todetermine whether ectopy, arrhythmia, or abnormality are present on theECG 1014. If any of these criteria are not met, the intensivist isprompted that cardiac injury is excluded 1016. If any of these criteriaare met, the intensivist is prompted that he should consider monitoringthe patient for an additional 24 hours 1018.

Referring to FIGS. 24A-B, the candiduria decision support algorithm,which is yet another decision support algorithm of the present inventionis illustrated. In the candiduria decision support algorithm, theintensivist is presented with the criteria for diagnosing candiduria, orsevere fungal infection. First, the intensivist determines whether thepatient has any medical conditions that render the patient prone tofungal infections, such as diabetes, GU anatomic abnormality, renaltransplant, or pyuria 1100. If there are no such conditions, theintensivist is next prompted by the system to look for dissemination orspreading of the fungal infection 1102. If the infection does not seemto have spread, the intensivist is prompted to change the patient'scatheter and test for pyuria after twenty four hours have passed 1104.

The intensivist is prompted by the system to determine whether thepatient can have P.O. 1106. If the patient can take P.O., the systemnext prompts the intensivist to determine whether azoles, an organiccompound for inhibiting fungal growth, have been administered in thepast three days to fight the infection 1108. If azoles have beenpreviously administered, the systemic infection diagnosis is confirmedand the intensivist is referred to the systemic amphotericin dosingalgorithm 1110. If azoles have not been previously administered,directions for the proper treatment dosage of fluconazole (a type ofazole) is provided to the intensivist along with adjustments for thespecies of fungus found 1112. Where the patient cannot take P.O., theintensivist is again referred to the systemic amphotericin dosingalgorithm 1114.

When the patient does have some condition prone to fungal infection, theintensivist is prompted to determine what other signs of disseminationare exhibited in the patient 1116. The intensivist is prompted to see ifthe patient can take P.O. If the patient cannot take P.O., theintensivist is referred to the systemic amphotericin dosing algorithm1120. If the patient can take P.O., the intensivist is prompted to checkwhether azoles have been administered in the previous three days 1122.If azoles have been administered, the systemic infection is confirmedand the intensivist is referred to the systemic amphotericin dosingalgorithm 1124. If no azoles have been administered previously, theintensivist is given instructions for administering fluconazole to treatthe fungal infection 1126.

If there is no evidence of dissemination, the intensivist is stillprompted to determine whether the patient can take P.O. 1128. Where thepatient cannot take P.O., directions are provided to administeramphotericin bladder washing procedures 1130. If the patient cannot takeP.O., the intensivist is prompted to determine whether azoles have beenadministered in the previous three days 1132. If azoles have beenadministered, the systemic infection is confirmed and the intensivist isreferred to the systemic amphotericin dosing algorithm 1134. If noazoles have been administered previously, the intensivist is giveninstructions for administering fluconazole to treat the fungal infection1136.

Referring to FIGS. 25A-B, the Cervical Spine Injury decision supportalgorithm of the present invention is illustrated. If an intensivistsuspects that a cervical spine injury may be present, the intensivistmay not be certain of all of the factors that would be indicative ofthis particular condition. Therefore, the intensivist is lead through adecision support algorithm, which first prompts the intensivist todetermine if the patient is awake, alert, not intoxicated, and has nomental status changes 1200. If these criteria are met, the intensivistis prompted to determine whether the patient has any neck pain 1202. Ifthe patient does not have any neck pain, the intensivist is prompted todetermine whether the patient has any other pain which would distractfrom his or her neck pain 1204. If this criterion is not met, theintensivist is prompted to determine whether the patient has anyneurologic deficits 1206. If this criterion is not met, the intensivistis prompted that a stable C-spine is present if the patient can flex,extend, move neck left/right without pain and without neck tenderness topalpitation 1208. The intensivist is prompted further that he can removethe collar 1208.

Alternatively, if the patient does have neck pain 1202, the intensivistis prompted to order 3 x rays 1210 consisting of: 1) lateral viewrevealing the base of the occiput to the upper border of the firstthoracic vertebra; 2) anteroposterior view revealing spinous processesof the second cervical through the first thoracic vertebra; and 3) anopen mouth odontoid view revealing the lateral masses of the firstcervical vertebra and entire odontoid process 1210. If the x rays arenormal the intensivist is prompted to consider extension then flexionlateral x rays; if normal he is prompted that he can remove the collar;if abnormal, he is prompted to obtain a surgical consult 1212. If the xrays are abnormal, the intensivist is prompted to obtain a surgicalconsult and order a CT scan 1214. If the x rays are indeterminate, theintensivist is prompted to order a CT scan 1216.

Alternatively, if the patient has no other pain which would distractfrom their neck pain 1204, the intensivist is prompted to order 3 x rays(the same types of x rays described in 1210 above with the sameprompting based on normal, abnormal, or indeterminate x rays) 1218.

If the patient does have neurologic deficits 1206, the intensivist isprompted to determine whether the neurologic deficit is referable to thecervical spine 1226. If this criterion is not met, the intensivist isprompted to order 3 x rays (the same types of x rays described in 1210above with the same prompting based on normal, abnormal, orindeterminate x rays) 1218. If the neurologic deficit is referable tothe cervical spine 1226, the intensivist is prompted that the patientshould obtain immediate spine trauma surgery consult and CT or MRI (ifavailable) 1228.

Alternatively, if the intensivist determines that the patient does notpass the criteria of being awake, alert, not intoxicated and having nomental status changes 1200, the intensivist is prompted to determinewhether the patient has severe head trauma 1232. If this criterion ismet, the intensivist is prompted to order CT of the neck with head CT1236. If this criterion is not met, the intensivist is prompted todetermine whether the patient has any neurologic deficit referable tothe cervical spine 1234. If the intensivist determines that the patientdoes have a neurologic deficit referable to the cervical spine, theintensivist is prompted that the patient should obtain immediate spinetrauma surgery consult and CT or MRI (if available) 1228. If theintensivist determines that the patient does not have a neurologicdeficit referable to the cervical spine 1234, he is prompted to order 3x rays (the same types of x rays described in 1210 above with the sameprompting based on normal, abnormal, or indeterminate x rays) 1218.

Referring to FIG. 26A-B, the Oliguria decision support algorithm of thepresent invention is illustrated. If an intensivist suspects thatOliguria may be present, the intensivist may not be certain of all ofthe aspects that would be indicative of this particular condition.Therefore, the intensivist is lead through a decision support algorithm,which first causes the intensivist to determine if the patient isoliguric, with the criterion being passage of less than 25 cc of urinein a period of 2 hours 1300. If this criterion is met the intensivist isprompted to determine whether the patient is anuric (the criterion forwhich is passage of less than 10 cc of urine in a 2 hour period) inspite of fluid administration 1302.

If this criterion is met, the intensivist is prompted to determinewhether the urinary catheter is working by flushing the catheter 1304.The intensivist is then prompted to determine whether the catheter isfunctioning 1306. If the catheter is not functioning, the intensivist isprompted to replace or reposition the catheter 1308. If the catheter isfunctioning, the intensivist is prompted to determine whether thepatient has a history of: 1) renal stone disease; 2) abdominal, pelvic,or retroperitoneal cancer; or 3) recent pelvic or retroperitonealsurgery 1310. If any of these criteria are met, the intensivist isprompted to perform the following actions: 1) do renal ultrasoundemergently to rule out obstruction; 2) while waiting for ultrasound,administer fluid at the rate of 7-15 ml/kg of bodyweight; and 3) sendurine for specific gravity determination 1312. Based on the renalultrasound test results, the intensivist is prompted to determinewhether an obstruction is present 1314. If an obstruction is determinedto be present, the intensivist is prompted to consult a urologistimmediately 1316.

Alternatively, if the intensivist determines that the patient does nothave a history of: 1) renal stone disease; 2) abdominal, pelvic, orretroperitoneal cancer; or 3) recent pelvic or retroperitoneal surgery1310, the intensivist is prompted to determine whether: 1) the patienthas a history of heart failure or known ejection fraction of less than30 percent; or 2) there are rales on the physical exam 1318.

Alternatively, if following the renal ultrasound test, the intensivistdetermines that there is no obstruction the intensivist is prompted todetermine whether: 1) the patient has a history of heart failure orknown ejection fraction of less than 30 percent; or 2) there are raleson the physical exam 1318.

If the intensivist determines that the patient is not anuric 1302, thenthe intensivist is prompted to determine whether: 1) the patient has ahistory of heart failure or known ejection fraction of less than 30percent; or 2) whether there are rales on the physical examination 1318.If neither of these criteria is met, the intensivist is prompted toadminister fluids to the patient at the rate of 10-20 ml/kg ofbodyweight 1320 and send the patient's urine sample for a specificgravity test 1322 as more fully described in FIGS. 26B-C.

Alternatively, if the patient does: 1) have a history of heart failureor known ejection fraction less than 30 percent; or 2) there are raleson the physical exam 1318, the intensivist is prompted to determinewhether there has been a chest x-ray (CXR) in the last 6 hours 1324. Ifthis criterion is not met, the intensivist is prompted to determinewhether there has been a change in respiratory status 1326. If there hasbeen no change in the respiratory status, the intensivist is prompted toadminister 7-15 ml of fluids per kg of bodyweight 1328 and to send thepatient's urine sample for a specific gravity test.

Alternatively, if the intensivist determines that there has been achange in respiratory status 1326, the intensivist is prompted to: 1) doa chest x-ray; and 2) determine whether there is evidence of edema orcongestion 1334. If there is evidence of edema or congestion 1334, theintensivist is prompted to: 1) insert a PA catheter to measure wedgepressure and liver function to direct fluid replacement; and 2) sendurine creatinine and sodium 1332.

If the intensivist determines that there has been a CXR in the last 6hours 1324, the intensivist is prompted to determine whether there isevidence of edema or congestion 1330. If there is no evidence of edemaor congestion, the intensivist is prompted to administer 7-15 ml offluids per kg of bodyweight 1328 and send the patient's urine for aspecific gravity test 1322.

Alternatively, if the intensivist determines there is evidence of edemaor congestion 1330, the intensivist is prompted to: 1) insert a PAcatheter to measure wedge pressure and liver function to direct fluidreplacement; and 2) send urine creatinine and sodium 1332.

Referring now to FIG. 26C-D, the oliguria algorithm descriptioncontinues. Following the specific gravity test of the patient's urine,the intensivist is prompted to determine whether the results indicatethe specific gravity is less than 1.018. If this criterion is met, theintensivist is prompted to: 1) send blood and urine immediately to testfor blood urea nitrogen (BUN), creatinine, electrolytes, and Hgb, andspot urine for creatinine, sodium, and sediment; and 2) administer 5-10ml of fluid per kg of bodyweight 1356. Once the results of these testsare obtained, the intensivist is prompted to determine what is the Hgb1338.

If the Hgb has increased by more than 1.5 gm/dl compared to the previousHgb 1340, the intensivist is prompted to: 1) administer fluids 5-10ml/kg of bodyweight and follow the urine output closely 1342. Followingthis, the intensivist is prompted to determine whether the labs confirmrenal failure by use of the formula FE.sub.Na=Urine Na.times.SerumCreatinine/Urine Creatinine.times.Serum Na.times.100 1344.

If the Hgb is within 1.5 gm/dl from the previous Hgb or no comparison1352, the intensivist is prompted to determine what is the mean bloodpressure 1354. If the mean blood pressure is determined to be within 20percent or higher than the baseline blood pressure 1356, the intensivistis prompted to determine whether the labs confirm renal failure 1344. Ifthe mean blood pressure is determined to be greater than 20 percentbelow the baseline pressure 1358, the intensivist is prompted to giveadditional fluids and consider invasive hemodynamic monitoring 1360.Following this, the intensivist is prompted to determine whether thelabs confirm renal failure by use of the formula FE.sub.Na=UrineNa.times.Serum Creatinine/Urine Creatinine.times. Serum Na.times.1001344.

Alternatively if the Hgb has decreased by 1.5 gm/dl compared to theprevious Hgb 1362, the intensivist is prompted to: 1) transfuse PRBCs asneeded; 2) look for source of bleeding and check PT, aPTT, & plateletcount 1364. Following this, the intensivist is prompted to determinewhat is the mean blood pressure 1354. If the mean blood pressure isdetermined to be greater than 20 percent below the baseline pressure1358, the intensivist is prompted to give additional fluids and considerinvasive hemodynamic monitoring 1360. Following this, the intensivist isprompted to determine whether the labs confirm renal failure by use ofthe formula FE.sub.Na=Urine Na.times.Serum Creatinine/UrineCreatinine.times.Serum Na.times.100 1344.

If the labs do not confirm renal failure, as indicated byFE.sub.Na.1toreq.1 percent 1346, the intensivist is prompted to: 1)continue to administer fluids and follow urine output; and 2) recheckcreatinine in 6-12 hours 1348.

Alternatively, if the labs do confirm renal failure, as indicated byFE.sub.Na>1 percent 1350, the intensivist is prompted to: 1) placecentral venous pressure (CVP); 2) Assure adequate intravascular volume;3) give trial of diuretics: 40 mg lasix IV, if no response in 1 hour,give hydrodiuril 500 mg IV, wait 20-30 minutes then give 100 mg lasix,if persistent oliguria, restrict: 1) fluids; 2) potassium & phosphate;if diuresis ensues, restrict only potassium & phosphate; in bothsituations, adjust all renally excreted medications; and 4) see acuterenal failure 1350.

Referring now to FIG. 26E, the oliguria algorithm description continues.Alternatively, following the specific gravity test of the patient'surine, the intensivist is prompted to determine whether the resultsindicate the specific gravity is greater than or equal to 1.018 1336. Ifthis criterion is not met 1364, the intensivist is prompted to determinewhether the urine is dark or tea colored 1366. If this criterion is met,the intensivist is prompted to: 1) check creatinine phospho/kinase; and2) force fluids to induce diuresis 1368.

If the intensivist determines that the urine is not dark or tea colored,the intensivist is prompted to: 1) administer 10-20 ml of fluids per kgof bodyweight; and 2) check Hgb 1370. The intensivist is then promptedto determine what is the Hgb 1372.

If the Hgb is determined to be greater than 1.5 gm/dl higher than theprevious Hgb 1374, the intensivist is directed to: 1) force fluids; and2) continue to follow the urine output 1376.

Alternatively, if the Hgb is determined to be within 1.5 gm/dl of thelast Hgb or there is no Hgb for comparison 1378, the intensivist isprompted to determine what is the mean blood pressure 1380. If the meanblood pressure is determined to be 20 percent or higher than thebaseline pressure 1382, the intensivist is prompted to: 1) continue toadminister fluids; 2) follow urine output; and 3) check creatinine in6-12 hours 1384. If the mean blood pressure is determined to be greaterthan 20 percent below the baseline pressure 1386, the intensivist isprompted to: 1) continue to push fluids; 2) consider invasivehemodynamic monitoring; and 3) if post-op abdominal trauma, considerabdominal compartment syndrome 1388.

If the Hgb is determined to be greater than 1.5 gm/dl below the previousHgb 1390, the intensivist is prompted to: 1) transfuse blood as needed;2) look for bleeding source; 3) check PT, aPPT & platelet count; 4)continue to push fluids; and 5) recheck Hgb in 1-2 hours 1392.

Referring to FIG. 27A-B, the open fractures decision support algorithmof the present invention is illustrated. Open fractures are where bone,cartilage, or a tooth break and push through the skin surface. Theintensivist is first prompted by the system to determine whether thepatient has an open fracture 1500. If one has occurred, the intensivistmust then determine whether the wound is contaminated with soil, or wasinflicted in a barnyard 1502 in order to address higher risk ofinfection. If the wound is contaminated with soil, or was inflicted in abarnyard, the intensivist is prompted to administer a high dose ofpenicillin to the antibiotics prescribed 1504. The intensivist is alsoprompted to take several treatment steps 1506. These treatment stepsinclude administering tetanus prophylaxis, such an antitoxin injection,monitoring staphylococcus aureus until twenty-four hours after surgery,caring for the wound within six hours, and where the injury is found tobe more severe during surgery, the intensivist is prompted to administeraminoglycosides for seventy two hours.

If the wound is not contaminated with soil, or was inflicted in abarnyard, the intensivist is next prompted to determine the severity ofthe wound 1508. To do so, the intensivist must determine the length ofthe wound and corresponding soft tissue damage. If the wound is eitherless than one centimeter and clean or greater than a centimeter longwithout extensive soft tissue damage, the intensivist is prompted totake several treatment steps 1506 as previously described. Where thesoft tissue damage is extensive or amputation has occurred, theintensivist is prompted by the system to make further determinations1510, 1512, 1514 about the wound caused by the fracture. The intensivistis prompted to determine if enough soft tissue coverage is remaining forthe wound to close and heal 1510, if any arterial repair is needed 1512,and if extensive soft tissue damage with periostitial injury, and boneexposure 1514. If there is adequate soft tissue coverage, theintensivist is advised that risk of infection is low and directed totake treatment actions 1516. If arterial damage requiring repair ispresent, the intensivist is advised by the system that risk of infectionis moderate to high and given treatment instructions 1518. Where thereis soft tissue injury with periostitial stripping and bone exposure, theintensivist is alerted by the system that risk of infection is high andgiven treatment instructions 1520. The treatment instructions in eachcase 1516, 1518, 1520 include administering tetanus prophylaxis, such anantitoxin injection, caring for the wound within six hours, andperforming: monitoring for staphylococcus aureus, and administeringaminoglycosides and high doses of penicillin, all for seventy two hoursbefore and after any operative procedures.

If the intensivist has determined that no exposed fracture has occurred,the system next prompts the intensivist to determine whether there isany evidence of neuro-vascular damage 1522. If there is evidence ofneuro-vascular damage, the intensivist is prompted to consult with anerosurgeon or vascular surgeon immediately 1524. If the intensivistdetermines there is no evidence of neuro-vascular damage to the patient,the system next prompts the intensivist to determine whether the patienthas compartment syndrome 1526. If there is evidence of compartmentsyndrome seen in the patient, the intensivist is prompted to consultorthopedics right away 1528. If there is no evidence of compartmentsyndrome seen in the patient, the intensivist is still prompted toconsult orthopedics, but without any prompt for time sensitivity 1530.

Referring to FIGS. 28A-B, the Pancreatitis diagnostic algorithm of thepresent invention is illustrated. To evaluate whether a patient haspancreatitis, the intensivist is first prompted to examine whethersevere epigastric abdominal pains and amylase levels three times greaterthan normal are present in the patient 1600. If neither or one of theconditions is present, the intensivist is prompted to consider othercauses of the abdominal pain, such as mesenteric ischemia, a perforatedulcer, intestinal obstruction, biliary colic, or an ectopic pregnancy1602.

If severe epigastric abdominal pains and amylase levels three timesgreater than normal are present, the intensivist is next prompted toprovide the Ranson Criteria which is a criteria associated with theseverity of pancreatitis and the potential outcome or prognosis at thatparticular level of severity, or Apache II score which is also a scoreassociated with the severity of the disease and the potential prognosisat a particular level of the patient 1604. If the patient has a RansonCriteria less than three or an Apache II score of less than eight, theintensivist is prompted by the system to consider removing the patientfrom the Intensive Care Unit 1606. However, if the patient has a RansonCriteria greater than three or an Apache II score of greater than eight,the intensivist is instructed to perform an abdominal ultrasound testwithin twenty-four hours 1607. If the results of the ultrasound testshow a biliary obstruction, the intensivist is instructed to considerperforming an ERCP to find and remove any gallstones 1608.

If the abdominal ultrasound results do not show any biliary obstruction,intensivist is next prompted to perform more diagnostic tests 1610. Theintensivist is directed to perform a Dynamic IV contrast and anabdominal Tomography (CT) scan. If the intensivist does not suspect asurgical condition exists, such as a perforated ulcer, mesentericinfarction or pancreatic infection, the tests may be performed afterthree days have passed. If the intensivist does suspect a surgicalcondition exists, the tests should be performed within three days. Ineither case, if the patient has creatinine levels greater than or equalto 2 miligrams per dl, the intensivist should not perform the Dynamic IVcontrast test.

Once the CT scan is performed, the intensivist is prompted to determinewhether necrotizing pancreatitis is present 1612. The intensivist isnext required to determine whether the patient has improved sinceadmission 1614. If no improvement has been seen, the intensivist isdirected to perform percutaneous fluid aspiration and do a gram stainculture the collected fluid 1616. If the culture shows infection 1618,the intensivist is directed to perform surgical debridement of thepancreas 1620. If the results of the culture are sterile 1622, theintensivist is directed to closely follow up on the patient's condition1624 and watch for clinical deterioration 1626. If the patient doesfurther deteriorate, the intensivist is then instructed to perform asurgical debridement of the pancreas 1628. If the patient does notdeteriorate, the intensivist is still prompted to closely follow thepatient's condition 1630.

Where the CT scan does not show signs of necrotizing pancreatitis 1612,the intensivist is prompted by the system to closely observe the patient1632. The intensivist is also prompted to check whether clinicaldeterioration is occurring 1634. If no deterioration is observed, theintensivist continues to observe the patient's condition 1636. Ifclinical deterioration is occurring 1634, the intensivist is directed toperform percutaneous fluid aspiration and do a gram stain culture thecollected fluid 1616. If the culture shows infection 1618, theintensivist is directed to order surgical debridement of the pancreas1620. If the results of the culture are sterile 1622, the intensivist isdirected to closely follow up on the patient's condition 1624 and watchfor clinical deterioration 1626. If the patient does furtherdeteriorate, the intensivist is then prompted to order a surgicaldebridement of the pancreas 1628. If the patient does not deteriorate,the intensivist is still directed by the system to closely follow thepatient's condition 1630.

Referring to FIGS. 29A-B, the penicillin allergy diagnosis algorithm ofthe present invention is illustrated. In order to diagnose a penicillinallergy, the intensivist is first prompted to determine whether thepatient has a history suggestive of previous penicillin or cephalosporinanaphylaxis 1700. Various known reactions, including angioedema,flushing, pruritis, airway obstruction, syncope, and hypertension, aredisplayed for the intensivist's review. If the patient has previouslyhad any of these reactions, the intensivist is prompted to determinewhether the patient has ever taken synthetic or partially syntheticantibiotics, such as ampicillin, amoxicillin, duricef or kefzol, withoutany anaphylaxis symptoms 1702. If the patient has taken syntheticswithout reaction, the intensivist is advised by the system thatpenicillin or cephalosporin may be administered 1716. If the patient hasreacted to synthetic or partially synthetic antibiotics, the intensivistis next prompted to determine whether the patient needs penicillin orcephalosporin specifically 1704.

If the patient is not required to have penicillin or cephalosporin, theintensivist is prompted to administer the synthetic antibiotics 1706. Ifthe patient does need penicillin or cephalosporin, the intensivist isdirected by the system to consider consulting with an allergist orimmunologist and perform skin tests for reactions 1708. Next, theintensivist is prompted to enter whether the skin test was positive1710. If the results are negative, the intensivist is further directedby the system to administer penicillin or cephalosporin with caution, toconsider pretreatment with benadryl or prednisone to counter anyreaction, and to closely monitor the patient 1712. If the results of theskin test are positive, the intensivist is prompted by the system toperform desensitization procedures 1714.

If the patient does not have a history suggestive of previous penicillinor cephalosporin anaphylaxis 1700, the intensivist is prompted todetermine whether the patient has previously experienced skin-levelreactions, such as exfoliative dermatitis, Stevens Johnson Syndrome, orToxic Epidernial Necrolysis, when given penicillin or cephalosporin1718. If the patient has previously experienced one of these reactions,the intensivist is directed by the system to administer an alternativeantibiotic 1720. If the patient has not experienced one of thesereactions, the intensivist is prompted to determine whether there is ahistory of any rash when given penicillin or cephalosporin 1722. If thepatient has not previously had a rash when given penicillin orcephalosporin, the intensivist is advised that the patient will mostlikely be able to take penicillin or cephalosporin 1724.

If the patient has previously experienced a rash when given penicillinor cephalosporin, the intensivist is prompted to determine whether therash presented when the patient was given ampicillin or amoxycillin1726. If the rash resulted from ampicillin or amoxycillin, theintensivist is next prompted to determine whether the rash wasurticarial 1728. If the rash was not urticarial, the intensivist isadvised by the system that the patient probably can take penicillin orcephalosporin, but should be closely monitored 1730. If the rash wasurticarial, the intensivist is prompted to determine whether or not thepatient needs penicillin or cephalosporin 1704.

If the patient is not required to have penicillin or cephalosporin, theintensivist is directed by the system to administer the syntheticantibiotics 1706. If the patient does need penicillin or cephalosporin,the intensivist is directed to consider consulting with an allergist orimmunologist and perform skin tests for reactions 1708. Next, theintensivist is prompted to enter whether the skin test was positive1710. If the results are negative, the intensivist is further directedto administer penicillin or cephalosporin with caution, to considerpretreatment with benadryl or prednisone to counter any reaction, and toclosely monitor the patient 1712. If the results of the skin test arepositive, the intensivist is directed to perform desensitizationprocedures 1714.

Referring to FIG. 30A-B, the Post-Op Hypertension decision supportalgorithm of the present invention is illustrated. If an intensivistdetermines that there may be a possibility of post-op hypertension, theintensivist may not be certain of all aspects that would be involved inthis particular condition. Therefore, the intensivist is lead through adecision support algorithm which prompts the intensivist to determinethe appropriate care to be given.

Initially, the intensivist is prompted to determine whether the patientis hypertensive (BP greater than 20 percent above mean baseline) 1800.If this criterion is met, the intensivist is prompted to determinewhether the patient has any of the causes of reversible hypertension: 1)hypercapnia; 2) bladder distension; 3) pain; 4) increased ICP; 5) drugs(pressors, cocaine, ketamine and chronic MAO use with indirect actingvasopressors); 6) automatic hyperreflexia; or 7) volume overload 1802.If any of these criteria are met, the intensivist is prompted to firsttreat those specific etiologies and, if pressure remains high, re-enteralgorithm 1804.

Alternatively, if none of these criteria are met 1802, the intensivistis prompted to determine whether the patient is at risk of injury frompost-op hypertension (i.e., vascular surgery, coronary artery disease,neurosurgery, ocular surgery, etc.) 1806. If this criterion is not met1806, the intensivist is prompted to determine whether the BP is greaterthan 40 percent above mean baseline 1808. If this criterion is not met,the intensivist is prompted that the patient may not need BP treatment1810.

If the BP is greater than 40 percent above the mean baseline 1808, theintensivist is prompted to determine whether the patient is in pain1812. If this criterion is met 1812, the intensivist is prompted totreat pain and continue 1814. Following this prompt 1814, theintensivist is prompted next to determine whether the patient isactively bleeding or at significant risk for post-op bleeding (i.e.,“moist closure” or high drain output) 1816. If either of these criteriais met 1816, the intensivist is prompted to use only short acting agentsincluding emolol and nitroprusside as needed until bleeding has abated1818.

Alternatively, if neither of these criteria is met 1816, the intensivistis prompted to determine whether the patient is tachycardic (absolutegreater than 90 bpm or ((relative greater than 15 percent overbaseline)) 1820. If either of these criteria is met 1820, theintensivist is prompted to go to Decision Table C, which is programmedfor the condition of a high heart rate. If neither of these criteria ismet 1820, the intensivist is prompted to eliminate (NOT C) Table C andproceed to the next decision point 1820.

HR↑Table C CAD Y Y Y N N N RAD N Y Y N Y N ↓EF N N Y N Y Y Treatment1^(ST) L E L L A E 2^(ND) E L A N N A

The intensivist is prompted next to determine whether the patient isbradycardic (absolute less than 60 bpm) 1822. If this criterion is met,the intensivist is prompted to go to Decision Table B, which isprogrammed for the condition of a low heart rate.

HR ↓ Table B CAD Y Y Y N N N RAD N Y Y N Y N ↓EF N N Y N Y Y Treatment1^(ST) N N A N A A 2^(ND) S S S H H H

If this criterion is not met, the intensivist is prompted to eliminate(NOT B) Table B and proceed to the next decision point 1822. [Note: IfNOT C and NOT B, the intensivist is prompted to go to Table A bydefault, i.e., If NOT C and NOT B Then A].

HR (nl) Table A CAD Y Y Y N N N RAD N Y Y N Y N ↓EF N N Y N Y YTreatment 1^(ST) L E A N A A 2^(ND) N N E A N N

The intensivist is prompted next to determine, sequentially, table inputvalues for CAD, RAD, and EF.

In these decision tables, the letter references have the followingmeanings: L=labetalol, E=esmolol, A=enalapril, N=nicardipine,H=hyrdalazine, S=nitroprusside. The reference to 1.sup.st and 2.sup.ndmeans that treatment should begin with the 1.sup.st drug and add orsubstitute the 2.sup.nd drug as needed.

Using the above decision tables, the intensivist is prompted todetermine whether the patient has known coronary artery disease (CAD) or3 or more risk factors for CAD 1824. If either of these criteria is met1824, the intensivist is prompted to enter a “Y” or “YES” for CAD intothe table selected above in 1820 and 1822. If neither of these criteriais met, the intensivist is prompted to enter a “N” or “NO” for CAD intothe table selected above in 1820 and 1822.

Next, the intensivist is prompted to determine whether the patient hasknown reactive airway disease (RAD)1826. If this criterion is met 1826,the intensivist is prompted to enter a “Y” or “YES” for RAD into thetable selected above in 1820 and 1822. If this criterion is not met, theintensivist is prompted to enter a “N” or “NO” for RAD into the tableselected above in 1820 and 1822.

Next, the intensivist is prompted to determine whether the patient hasknown EF less than 30 percent or a history of systolic heart failure1828. If either of these criteria is met 1828, the intensivist isprompted to enter a “Y” or “YES” for EF into the table selected above in1820 and 1822. If neither of these criteria is met 1828, the intensivistis prompted to enter a “N” or “NO” for EF into the table selected abovein 1820 and 1822.

Based on the table selected in 1820 and 1822 above, and the table inputsdetermined from 1824, 1826, and 1828, the intensivist is prompted withthe proper medication to administer for the 1.sup.st and 2.sup.ndtreatment.

If the patient is not in pain 1812, the intensivist is prompted toemploy the procedures described above in 1816.

If the patient is at risk of injury from post-op hypertension 1806, theintensivist is prompted to determine whether the blood pressure isgreater than 40 percent above baseline 1830. If this criterion is met1830, the intensivist is prompted to employ the procedures describedabove in 1812.

Alternatively, if this criterion is not met 1830, the intensivist isprompted to determine whether the patient is in pain 1836. If thiscriterion is met 1836, the intensivist is prompted to treat pain andreevaluate following analgesia and, if still hypertensive, to continuealgorithm 1838. Following this action 1838, the intensivist is promptedto employ the procedures described above in 1816. If the patient is notin pain 1836, the intensivist is prompted to employ the proceduresdescribed above in 1816.

If the patient is determined not to be hypertensive 1800, theintensivist is prompted to determine whether the patient requires theirBP controlled near baseline (i.e., neurosurgery, carotid surgery,thoracic aorta surgery) 1832. If this criterion is not met 1832, theintensivist is prompted that the patient probably does not needtreatment 1834.

Alternatively, if this criterion is met 1832, the intensivist isprompted to employ the procedures described above in 1836.

Referring to FIG. 31A, the pulmonary embolism diagnosis algorithm isillustrated. If a pulmonary embolism is suspected, the intensivist isfirst prompted to determine whether the patient is hemodynamicallyunstable 2900. If the patient is hemodynamically unstable, theintensivist is directed by the system to consider performing animmediate transthoracic echocardiogram, pulmonary angiogram andtreatment consistent with massive pulmonary embolism 2902. If thepatient is not hemodynamically unstable, the intensivist is prompted toperform a VQ scan and perform further assessment of the patient 2904.

In order to further assess the patient, the intensivist is prompted torespond to a series of questions 2906, 2908, 2910, 2912. The intensivistis prompted to determine whether any of the following patient conditionsare present: Dyspnea, Worsening chronic dyspnea, Pleuritic chest pain,Chest pain that is non-retro sternal & non-pleuritic, O.sub.2saturation<92% on room air that corrects with 40% O.sub.2supplementation, Hemoptysis, or Pleural rub 2906. The intensivist isalso prompted to determine whether any risk factors are in the patient'shistory, such as: Surgery within 12 weeks, Immobilization (complete bedrest) for >3 days within 4 weeks, Previous DVT or objectively diagnosedPE, Lower extremity fracture & immobilization within 12 weeks, Strongfamily history of DVT or PE(.gtoreq.2 family members with objectiveproven events or 1.sup.st degree relative with hereditarythrombophilia), Cancer (treatment within the last 6 months or palliativestages), Postpartum, or Lower extremity paralysis 2908. Further, theintensivist must determine whether the patient has any of the followingsymptoms: Heart rate>90 beats/min, Temp.gtoreq.38.0, CXR free ofabnormalities (edema, pneumonia, pneumothorax), or Leg symptoms c/w DVT,syncope, blood pressure less than 90 mm Hg with heart rate greater than100 beats/min, receiving mechanical ventilation and/or oxygensupplementation greater than 40%, and new onset or right heart failure(-JVP, new S1, Q3, T3, or RBBB) 2910. The intensivist is also queried bythe system to consider alternative diagnosis that may be more likelythan pulmonary embolism. To do so, the intensivist is prompted toconsider conditions that simulate major pulmonary embolism, such asmyocardial infarction, acute infection with COPD, septic Shock,dissecting aortic aneurysm, or occult hemorrhage. The intensivist isadditionally prompted to consider conditions that simulate minorpulmonary embolism, such as acute bronchitis, pericarditis, viralpleurisy, pneumonia, and esophageal spasm 2912.

Referring to FIG. 31B, the pulmonary embolism algorithm descriptioncontinues. The intensivist enters the answers to the assessment queriesposed 2906, 2908, 2910, 2912 into the system. If two or more responsesto the patient condition query 2906 were answered yes and one or morequestions were answered yes from: Heart rate>90 beats/min,Temp.gtoreq.38.0, CXR free of abnormalities, or Leg symptoms c/w DVT ofthe symptoms query 2910, the intensivist is informed that a typicalpulmonary embolism is present 2914. Next, the system compares thisresponse to the answer to the alternative diagnosis query 2912. If analternative diagnosis is at least as likely as pulmonary embolism 2916,the intensivist is also given a low probability 2918 to moderateprobability 2920 risk factor. If an alternative diagnosis is less likelythan pulmonary embolism 2922, the intensivist is given a moderate 2924to high 2926 probability risk factor.

If less than two yes answers resulted from the patient conditions 2906,the intensivist is advised by the system that an atypical pulmonaryembolism may be present 2928. Next, the system compares this response tothe answer to the alternative diagnosis query 2912. If an alternativediagnosis is at least as likely as pulmonary embolism 2930, theintensivist is told there is no risk and low probability 2932 or somerisk with a low probability 2934 risk factor. If an alternativediagnosis is less likely than pulmonary embolism 2934, the intensivistis given a no risk and low probability 2938 to risk but moderateprobability 2940.

If at least one answer to the symptoms of syncope, blood pressure lessthan 90 mm Hg with heart rate greater than 100 beats/min, receivingmechanical ventilation and/or oxygen supplementation greater than 40%,and new onset or right heart failure 2910 is yes, the intensivist isprompted with a message that severe pulmonary embolism is occurring2942. Next, the system compares this response to the answer to thealternative diagnosis query 2912. If an alternative diagnosis is atleast as likely as pulmonary embolism 2944, the intensivist is toldthere is a moderate probability of pulmonary embolism 2946. If analternative diagnosis is less likely than pulmonary embolism 2948, theintensivist is notified that a high probability of pulmonary embolism ispresent 2950.

Once the risk factors and probabilities are determined the systemcompares this information to the VQ scan results. This comparison isperformed according to the following Table 4 below.

TABLE 4 Probability table Input Clinical Probability V/Q Scan HighModerate Low High A A B Intermediate B C C Low B C E Normal E E E

Where the VQ scan column and the risk column intersect, a letter code isassigned to various treatment instructions. The treatment instructionsare as follows.

-   A=Pulmonary embolus diagnosed. Begin treatment-   E=Pulmonary embolus excluded-   B=Proceed with the following work-up:    -   1) Perform spira CT(If patient has real insufficiency        [creatinine>2.0],consider going directly to pulmonary angiogram        to reduce the potential dye load). If positive begin treatment,    -   2) If negative, assess for DVT using compression ultrasound or        venography. If positive begin treatment,    -   3) If negative, perform pulmonary angiogram. If positive begin        treatment, if negative diagnosis excluded.-   C=Proceed with the following work-up:    -   1) Perform spiral CT. If positive begin treatment,    -   2) If negative, assess for DVT using compression ultrasound or        venography. If positive begin treatment,    -   3) If negative perform D-dimer assay(elisa only). If negative        diagnosis excluded, If positive, perform serial ultrasound of        the lower extremities.

Once the correlation is made, the instructions associated with theletter code are displayed by the system to prompt the intensivist withdiagnosis and treatment instructions.

Referring to FIG. 32, the seizure decision support algorithm of thepresent invention is illustrated. If an intensivist encounters seizurein a patient, he may not be certain of all of the aspects and thetimelines that are critical to treating this particular condition.Therefore, the intensivist is lead through a decision support algorithm,which divides the treatment sequence into three segments: 0-30 minutes;30-60 minutes; and beyond 60 minutes.

At the onset of a seizure, in the 0-30 minute segment of the algorithm,the intensivist is prompted to give the patient lorazepam (0.1 mg/kg ofbodyweight) in 2 mg boluses up to 8 mg 2000. Subsequently, theintensivist is prompted to give the patient phenytoin (18-20 mg/kg ofbodyweight) at 50 mg/min of fosphenytoin (18-20 mg/kg of bodyweight) at150 mg/min followed by 5 mg/kg of bodyweight/day through separate IVline 2002.

During the 30-60 minute segment of the algorithm, the intensivist isprompted to: reload additional phenytoin or fosphenytoin (10 mg/kg ofbodyweight) maintaining previous infusion; and give additional lorazepam(0.05 mg/kg of bodyweight) 2004. Subsequently, the intensivist isprompted to begin continuous EEG monitoring 2006.

The intensivist is then prompted to determine whether the patient ishemodynamically stable 2008. If hemodynamically stable, the intensivistis prompted to administer propofol 1-2 mg/kg of bodyweight bolusfollowed by 2-10 mg/kg/hr 2010.

At the 60 minute segment of the algorithm, the intensivist is promptedthat if seizure activity stops, he should taper either midazolam orpropofol over the next 12-24 hours while maintaining phenytoin but ifseizures persist, he is prompted to move to the pentobarbital coma block2012.

Under pentobarbital coma, the intensivist is prompted to administer10-15 mg/kg/hr and to maintain until seizure control is achieved on EEG2014. The intensivist is prompted further that the patient usuallyrequires PA catheter and pressors to maintain hemodynamic control 2014.

Alternatively, if the patient is determined to be hemodynamicallyunstable 2016, the intensivist is prompted to utilize fluids andpressors as needed (phynylephrine or dopamine) midazolam 0.2 mg/kg bolusfollowed by 0.1-2.0 mg/kg/hr 2018.

At the 60 minute segment of the algorithm, the intensivist is promptedthat if seizure activity stops, he should taper either midazolam orpropofol over the next 12-24 hours while maintain phenytoin but ifseizures persist, he is prompted to move to the pentobarbital coma block2012.

Under pentobarbital coma, the intensivist is prompted to administer10-15 mg/kg/hr and to maintain until seizure control is achieved on EEG2014. The intensivist is prompted further that the patient usuallyrequires PA catheter and pressors to maintain hemodynamic control 2014.

Referring to FIGS. 33A-B, the supra ventricular tachycardia (SVT)decision support algorithm of the present invention is illustrated. Ifan intensivist determines that SVT is present, the intensivist may notbe certain of all aspects that would be involved in treating thisparticular condition. Therefore, the intensivist is lead through adecision support algorithm which prompts the intensivist to determinethe appropriate care to be given.

Initially, the intensivist is prompted to determine whether SVT isstable or unstable 2100. If SVT is stable 2102, the intensivist isprompted to determine whether the patient has a regular or irregularrhythm 2102. If the patient has a regular rhythm 2104, the intensivistis prompted to determine whether there is a wide complex or a narrowcomplex 2104. If the intensivist determines that there is a wide complex2106, the intensivist is prompted to administer adenosine 6 mg/12 mg (ifneeded) 2108. Following the administering of adenosine 2108, theintensivist is prompted to consider that if the patient converts tosinus rhythm (SR) to—consider re-entrant junctional or WPW re-entrant.If the wide complex recurs, treat the patient with esmolol or Ca+2blockers.

Alternatively; if no effect, the intensivist is prompted to considerV-tach 2112. Next, the intensivist is prompted to: 1) load procainamide150 mg over 10 min, then 1 mg/min infusion; and 2) synchronizedcardiovert 2114.

Alternatively, if the wide complex slows, the intensivist is prompted toconsider SVT w/aberrancy and continue to slow with esmolol or Ca+2blockers 2116.

The intensivist is prompted next to administer esmolol/calcium blockersand link to ventricular rate control 2118. The intensivist is promptednext to determine whether there has been a conversion to SR 2120. Ifthere is no conversion to SR in 24 hours, the intensivist is prompted toadd antiarrhythmic agent and consider anticoagulation 2122. Theintensivist is prompted next to determine whether there has beenconversion to SR. If conversion to SR, the intensivist is prompted tocontinue maintenance antiarrhythmic agent during hospitalization 2124.If no conversion to SR, the intensivist is prompted to cardiovert whileon antiarrhythmic & following heparinization 2126.

If the patient has a regular rhythm 2104, the intensivist is prompted todetermine whether there is a wide complex or a narrow complex 2104. Ifthe intensivist determines that there is a narrow complex 2128, theintensivist is prompted to to administer adenosine 6 mg/12 mg (ifneeded) 2130. If administering the adenosine 2130 slows the ventricularrate only and the atrial rate persists, the intensivist is prompted toconsider atrial flutter and continue to slow with esmolol or Ca+2blockers 2132. The intensivist is prompted next to employ the proceduresdescribed above in 2118.

If administering the adenosine 2130 converts the patient to SR, theintensivist is prompted to consider re-entrant sinus or junctional andif recurs, treat with esmolol or Ca+2 blockers 2134.

If administering the adenosine 2130 slows both atrial and ventricularrates the intensivist is prompted that there is a probable sinustachycardia 2136. The intensivist is prompted next to continue to slowwith esmolol 2138. The intensivist is prompted next to employ theprocedures described above in 2118.

If SVT is stable 2102, the intensivist is also prompted to determinewhether the patient has a regular or irregular rhythm 2102. If thepatient has an irregular rhythm 2140, the intensivist is prompted thatif no p waves, there is probable Atrial fibrillation 2142. Theintensivist is prompted next to slow ventricular response with esmololor Ca+2 blockers 2144. The intensivist is prompted next to employ theprocedures described above in 2118.

If the patient has an irregular rhythm 2140, the intensivist is promptedto determine whether there are more than 3 p wave types MAT—and to treatunderlying lung dz. and avoid theophylline compounds 2146. Theintensivist is prompted next to slow rate with Ca+2 blockers only 2148.The intensivist is prompted next to employ the procedures describedabove in 2118.

Referring now to FIG. 33C, the description of the SVT decision algorithmcontinues. If SVT is unstable 2101, the intensivist is prompted todetermine whether the patient has SBP less than 80, ischemia, mentalstatus changes 2150. The intensivist is prompted next to performsynchronous cardioversion (100 J, 200 J, 300 J) 2152. The intensivist isprompted next that if sinus rhythm: 1) correct reversible etiologies; 2)consider starting IV antiarrhythmic for maintenance of sinus rhythm2154. Alternatively, following 2152, the intensivist is prompted nextthat if continued SVT: 1) correct reversible etiologies; 2) load IVantiarrhythmic (see dosing guidelines) and repeat DC cardioversion 2156.

For example, and without limitations, wide complex QRS Tachycardia isalso addressed in the decision support algorithm of the presentinvention. Referring to FIGS. 34A-B, the wide complex QRS tachycardiadecision support algorithm is illustrated. If an intensivist determinesthat there may be a possibility of wide complex QRS tachycardia, theintensivist may not be certain of all aspects that would be involved inthis particular condition. Therefore, the intensivist is lead through adecision support algorithm which prompts the intensivist to determinethe appropriate care to be given.

Initially, the intensivist is prompted to determine whether the patientis hemodynamically stable (no angina, heart failure, or hypotension(systolic less than 80 mm)) 2200. If this criterion is not met, theintensivist is prompted to go to the cardio-pulmonary guidelinesalgorithm which is generally known to those skilled in the art.

Alternatively, if this criterion is met, the intensivist is prompted todetermine whether the patient is within 7 days of a myocardialinfarction or at risk for myocardial ischemia 2202. If the patient isnot within 7 days of a myocardial infarction or at risk for myocardialischemia 2202, the intensivist is prompted to determine whether the widecomplex QRS rhythm is sustained (greater than 30 seconds) 2234. If thiscriterion is not met, the intensivist is prompted to determined whetherthe QRS is monomorphic 2236. If the QRS is monomorphic 2236, the tointensivist is prompted to determine whether the patient has structuralheart disease 2242. If the patient has structural heart disease 2242,the intensivist is prompted to: 1) monitor closely; 2) look forreversible etiologies; and 3) consider antiarrhythmic therapy 2244. Ifthe patient does not have structural heart disease 2242, the intensivistis prompted to: 1) monitor closely; 2) look for reversible etiologies;and 3) if recurs and symptomatic may require further testing (prolongedholter or EP study) 2246.

If the QRS is not monomorphic 2236, the intensivist is prompted todetermine whether the QT is prolonged 2238. If this criterion is met,the intensivist is prompted to: 1) check K; 2) give Mg; and 3) consideroverdrive pacing 2240. If the intensivist determines that the QT is notprolonged, 2238, the intensivist is prompted to employ the proceduresdescribed above in 2242.

If the wide complex QRS rhythm is sustained 2234, the intensivist isprompted to determine whether the rhythm is polymorphic or irregular2208. If the rhythm is polymorphic or irregular, the intensivist isprompted to consider atrial fibrillation with accessory pathwayconduction and load with procainamide and get a cardiology consultation2210. If the rhythm is not polymorphic or irregular, the intensivist isprompted with the question of whether he wishes to: 1) perform ECGdiagnosis; or 2) administer adenosine diagnostically 2220. If theintensivist makes the determination to perform an ECG diagnosis 2220, heis prompted to go to the ECG diagnosis algorithm 2300.

If the intensivist makes the determination to administer adenosinediagnostically 2220, he is prompted to go to the administer adenosinebranch of the algorithm 2222. If there is no effect, the intensivist isprompted that there is probable VT and to determine whether the VT ismonomorphic 2224. If the VT is monomorphic 2224, the intensivist isprompted to load with procainamide and perform synchronous cardioversion2226.

Alternatively, if the VT is not monomorphic 2224, the intensivist isprompted to load with lidocaine and perform immediate cardioversion2228.

If the ventricular response is slowed after administering adenosine2222, the intensivist is prompted to consider SVT with aberrancy andtreat with esmolol or Ca blockers 2230.

If the ventricular response converts to sinus rhythm after administeringadenosine 2222, the intensivist is prompted: to consider re-entrantmechanism with BBB or WPW; and, 1) if WPW consult cardiology forpossible ablation 2232.

If the patient is within 7 days of a myocardial infarction or at riskfor myocardial ischemia 2202, the intensivist is prompted to determinewhether the wide complex is sustained (30 seconds) 2204. If the widecomplex is not sustained 2204, the intensivist is prompted to determinewhether the patient: 1) symptomatic; 2) tachycardia runs are frequent;or 3) the tachycardia rates are rapid (greater than 180) 2212. If noneof these criteria is met, the intensivist is prompted to observe 2216.Alternatively, if any of these criteria is met 2212, the intensivist isprompted to: 1) administer lidocaine 100-200 mg & 1-4 mg/min infusion;and 2) amiodarone 2214.

If the wide complex is sustained 2204, the intensivist is prompted todetermine whether the rate is greater than 140/min 2206. If thiscriterion is not met 2206, the intensivist is prompted: to consideraccelerated idioventricular, and that in some patients this can lead tohemodynamic compromise; and that 1) he can perform overdrive pacing ifneeded 2218.

Alternatively, if this criterion is met, the intensivist is prompted tofollow the procedures in 2208.

If the intensivist makes the determination to perform ECG Diagnosis2220, he is prompted to go to the ECG Diagnosis branch of the algorithm2220. Referring now to FIG. 34C, in the ECG Diagnosis branch, theintensivist is prompted to determine whether the patient has knownpre-excitation syndrome 2300. If this criterion is met, the intensivistis prompted to determine whether the QRS complexes are predominantlynegative in leads V4-V62302. If the QRS complexes are predominantlynegative in leads V4-V6, the intensivist is prompted that there isprobable VT 2304.

If the QRS complexes are not predominantly negative in leads V4-V62302,the intensivist is prompted to determine whether there is a QR complexin one or more of leads V2-V62306. If this criterion is met, theintensivist is prompted that there is probable VT 2308.

Alternatively, if this criterion is not met 2306, the intensivist isprompted to determine whether there are more QRS complexes than P waves2310. If there are more QRS complexes than P waves 2310, the intensivistis prompted that there is probable VT 2312. If there are not more QRScomplexes than P waves 2310, the intensivist is prompted: to considerpre-excited SVT; and that he may wish to perform EP study 2314.

If the intensivist determines that the patient does not have knownpre-excitation syndrome 2300, the intensivist is prompted to determinewhether there is an RS complex present in any precordial lead 2316. Ifthis criterion is not met 2316, the intensivist is prompted that thereis probable VT 2318.

Alternatively, if this criterion is met 2316, the intensivist isprompted to determine whether the R to S interval is greater than 100 MSin any one precordial lead 2320. If this criterion is met, theintensivist is prompted that there is probable VT 2322.

If the R to S interval is not greater than 100 MS in any one precordiallead 2320, the intensivist is prompted to determine whether there isevidence of atrioventricular dissociation 2324. If this criterion ismet, the intensivist is prompted that there is probable VT 2326.

Alternatively, if there is no evidence of atrioventricular dissociation2324, the intensivist is prompted to determine whether V-1 is negativeand V-6 positive and QRS greater than 0.14 mSEC 2328. If these criteriaare met, the intensivist is prompted that there is probable VT 2330.

If none of these criteria is met 2328, the intensivist is prompted thatthe situation may represent SVT with aberrancy or underlying bundlebranch block 2332.

Referring to FIG. 35A, the assessment of sedation algorithm of thepresent invention is illustrated. If an intensivist encounters a needfor sedation, he may not be certain of all of the aspects and thetimelines that are critical to this particular process. Therefore, theintensivist is lead through a decision support algorithm, which promptsthe intensivist to address a number of factors in the process 3100.

The intensivist is prompted initially to go to the Scoring section ofthe algorithm 3100. The intensivist is prompted to proceed through anumber of scorings 3102 and to first score the patient's alertness withpoints being allocated in the following manner: asleep/unresponsive=0;responsive to voice=1; and hyperresponsive=2 3104.

The intensivist is prompted next to score the patient's movement withpoints being allocated in the following manner: no spontaneousmovement=0; spontaneous movement=1; and pulls at lines, tubes,dressings=2 3106.

The intensivist is prompted next to score the patient's respirationbased on whether the patient is mechanically ventilated or spontaneouslybreathing with points being allocated as subsequently discussed. If thepatient is mechanically ventilated, the intensivist is prompted toallocate points in the following manner: no spontaneous ventilation=0;spontaneous ventilations and synchronous with ventilator=1; orspontaneous ventilations with cough or dysynchrony>10 percent ofbreaths=2 3108. Alternatively, if the patient is spontaneouslybreathing, the intensivist is prompted to allocate points in thefollowing manner: respiration rate (RR)<10=0; RR=10-30=1; or RR>30=23108.

The intensivist is prompted next to score the patient's heart rate withpoints being allocated in the following manner: >20 percent below meanfor last 4 hr=0; within 20 percent mean for last 4 hr=1; or >20 percentabove mean for last 4 hr=2 3110.

The intensivist is prompted next to score the patient's blood pressurewith points being allocated in the following manner: MAP>20 percent forlast 4 hr=0; MAP within 20 percent mean for last 4 hr=1; or MAP>20percent above mean for last 4 hr=2 3112.

The intensivist is prompted next to determine the sedation score by thefollowing formula: SEDATION SCORE=alertness+movement+respirations+heartrate+blood pressure 3114. In one embodiment, respiratory rate, heartrate, and BP can be computer linked to monitor data thereby simplifyingthe sedation scoring assessment. The nursing observations are deemedintuitive and the nursing burden in sedation scoring can be minimal byusing this point scoring.

Referring now to FIG. 35B, the sedation assessment algorithm descriptioncontinues. The intensivist is prompted then to continue the sedationassessment by moving to the Pain Assessment section of the algorithm3116.

In the Pain Assessment section, the intensivist is prompted to determinewhether the patient is conscious, communicative, and acknowledging pain3118. If any of these criteria is not met, the intensivist is promptedto determine: whether the sedation score is greater than 2 and thepatient: is known to be in pain before becoming uncommunicative; or S/precent surgery; or having tissue ischemia or infarct; or has wounds; orhas large tumor possibly impinging on nerves. If the answer to either ofthese two questions is YES, the intensivist is prompted to treat forpain 3118. The intensivist is prompted then to continue the assessmentby moving to the Delirium Assessment section of the algorithm 3118.

In the Delirium Assessment section, the intensivist is prompted todetermine whether the sedation score is greater than 2 AND the patienthas: day/night reversal with increased agitation at night OR eyes openand “awake” but disoriented; or eyes open and “awake” but pulling atlines, tubes, or dressings OR difficult to sedate prior to ventilatorweaning OR paradoxical response to benzodiazepines. If these criteria ismet, the intensivist is prompted to consider butyrophenone 3120.

Referring to FIG. 36, the Bolus sliding scale algorithm is illustrated.If an intensivist encounters a need for sedation, the algorithm forwhich may contain a reference to the bolus sliding scale for midazolam,he may not be certain of all of the aspects which are critical to thisscale. Therefore, the intensivist is lead through a decision supportalgorithm, which prompts the intensivist through the use of the scale3200.

If lorazepam is less than 0-2 mg IV q 6 hr, then the intensivist isprompted to give midazolam 1-2 mg q 5 min until adequately sedated 3202.

Alternatively, if lorazepam equals 2-4 mg IV q 4 hr, then theintensivist is prompted to give midazolam 2 mg q 5 min until adequatelysedated 3202.

Alternatively, if lorazapam is greater than 10 mg IV q 4 hr, then theintensivist is prompted to give midazolam 5 mg q 5 min until adequatelyAND consider fentanyl and/or droperidol or Haldol for synergy despitedelirium and pain assessment 3202.

Yet another decision support routine is the sedation algorithm. Referngto FIG. 37, the sedation process decision support algorithm isillustrated. If an intensivist determines that a patient will requiresedation, the intensivist may not be certain of all aspects that wouldbe involved in this particular process. Therefore, the intensivist islead through a decision support algorithm, which prompts the intensivistto conduct a sedation assessment based on: 1) scoring; 2) pain; and 3)delirium (see Assessment of Sedation algorithm) 3300.

Following completion of the sedation assessment process 3300, theintensivist is prompted to determine whether the patient is in pain3302. If this criterion is met, the intensivist is prompted toadminister bolus morphine, fentanyl, other narcotic, start patientcontrolled analgesic (PCA) or epidural analgesia as indicated 3324. Ifthe patient is not in pain 3302 or after administering bolus morphine,fentanyl, other narcotic, start patient controlled analgesic (PCA) orepidural analgesia as indicated 3324, the intensivist is prompted todetermine whether the patient is delirious 3304.

If the intensivist determines that the patient is delirious 3304, he isprompted to administer droperidol 2.5-5 mg q 30 min pm and that he mayconsider IV Haldol not to exceed 30 mg/24 hr 3326. If the patient is notdelirious or after following the procedures in 3326, the intensivist isprompted to determine whether the patient will need sedation for morethan the next 24 hours 3306. If the patient will not need sedation formore than the next 24 hours 3306, the process continues as described inFIG. 38.

Alternatively, if the patient will need sedation for more than the next24 hours 3306, the intensivist is prompted to determine whether thesedation score is 8-10 3308. If this criterion is met, the intensivistis prompted to employ the Bolus sliding scale midazolam and increaselorazepam by 20 percent 3328 (see Bolus sliding scale midazolamalgorithm—FIG. 36). Subsequently, the intensivist is prompted toreassess sedation in 4 hr 3330.

Alternatively, if the patient will need sedation for more than the next24 hours 3306, the intensivist is prompted to determine whether thesedation score is 8-10 3308. If this criterion is met, the intensivistis prompted to employ the Bolus sliding scale midazolam and increaselorazepam by 20 percent 3328 (see Bolus sliding scale midazolamalgorithm—FIG. 42). Subsequently, the intensivist is prompted toreassess sedation in 4 hr 3330.

If the sedation score is not 8-10, the intensivist is prompted todetermine whether the sedation score is greater than or equal to thelast Sed Scr after sedative bolus or increase 3310. If this criterion ismet, the intensivist is prompted to employ the procedures describedabove in 3328 and 3330.

If the sedation score is not greater than or equal to the last Sed Scrafter sedative bolus or increase 3310, the intensivist is prompted todetermine whether four (4) or more midaz boluses have been given sincelast q 4 hr assessment 3312. If this criterion is met, the intensivistis prompted to employ the procedures described above in 3328 and 3330.

Alternatively, if less than four (4) midaz boluses have been given sincelast q 4 hr assessment 3312, the intensivist is prompted to determinewhether the patient is adequately sedated 3314. If this criterion is notmet, the intensivist is prompted to employ the procedure described in3328 and 3330.

If the intensivist determines that the patient is adequately sedated3314, the intensivist is prompted to determine whether the sedationscore is 0-2 3316. If this criterion is met, the intensivist is promptedto decrease lorazepam by 20 percent 3332 and reassess sedation in 4 hr3334.

Alternatively, if the sedation score is not 0-2 3316, the intensivist isprompted to determine whether the sedation score is less than or equalto the last Sed Scr after sedative decrease 3318. If this criterion ismet, the intensivist is prompted to employ the procedure described in3332 and 3334.

If the sedation score is not less than or equal to the last Sec Scrafter sedative increase 3318, the intensivist is prompted to determinewhether the patient is clinically oversedated 3320. If the patient isclinically oversedated 3320, the intensivist is prompted to employ theprocedure described in 3332 and 3334. If the patient is not clinicallyoversedated 3320, the intensivist is prompted to reassess sedation in 4hr 3322.

Referring to FIG. 38, the short term sedation process decision supportalgorithm of the present invention is illustrated. If an intensivistdetermines that a patient will not require sedation past the next 24hour period, the intensivist may not be certain of all aspects thatwould be involved in this particular process. Therefore, the intensivistis lead through a decision support algorithm, which prompts theintensivist to conduct a sedation assessment based on: 1) scoring; 2)pain; and 3) delirium (see Assessment of Sedation algorithm) 3100.

Following completion of the sedation assessment process 3100, theintensivist is prompted to decrease lorazepam by 20 percent frombaseline per day 3102. The intensivist is prompted next to determinewhether the patient is in pain 3104. If this criterion is met, theintensivist is prompted to administer bolus morphine or fentanyl 3122.If the patient is not in pain or after administering bolus morphine orfentanyl 3122, the intensivist is prompted to determine whether thepatient is delirious 3106.

If the intensivist determines that the patient is delirious, he isprompted to administer droperidol 2.5-5 mg q30 min pm 3124. If thepatient is not delirious or after administering droperidol 3124, theintensivist is prompted to determine whether the sedation score is 8-103108.

If this criterion is met, the intensivist is prompted to employ theBolus sliding scale midazolam (see Bolus sliding scale midazolamalgorithm) and begin midazolam infusion or begin propofol 1-2 mg/kgbolus and 5-50 mcg/kg/min infusion 3126. Subsequently, the intensivistis prompted to reassess sedation in 1 hr 3128.

If the sedation score is not 8-10, the intensivist is prompted todetermine whether the sedation score is greater than or equal to thelast Sed Scr after sedative bolus or increase 3110. If this criterion ismet, the intensivist is prompted to employ the procedures describedabove in 3126 and 3128.

If the intensivist determines that the sedation score is not greaterthan the last sedation score after sedative bolus or increase 3110, theintensivist is prompted to determine whether the patient is adequatelysedated 3112. If this criterion is not met, the intensivist is promptedto employ the procedures described above in 3126 and 3128.

If the intensivist determines that the patient is adequately sedated3112, he is prompted to determine whether the sedation score is 0-23114. If this criterion is met, the intensivist is prompted to determineif the patient has been sedated for more than 72 hours 3130. If thepatient has not been sedated for more than 72 hours 3130, theintensivist is prompted to hold midazolam or propofol and hold ordecrease lorazepam by 50 percent 3132. The intensivist is promptedsubsequently to reassess sedation in 1 hour 3134.

Alternatively, if the intensivist determines that the patient has beensedated for more than 72 hours 3130, the intensivist is prompted to holdmidazolam or propofol and decrease lorazepam by 20 percent per day 3136.The intensivist is prompted subsequently to reassess sedation in 1 hour3134.

Alternatively, if the intensivist determines that the sedation score isnot 0-2 3114, the intensivist is prompted to determine whether thesedation score is less than or equal to the last sedation screeningafter sedative decrease 3116. If this criterion is met, the intensivistis prompted to determine whether the patient has been sedated for morethan 72 hours and to follow the procedures described above in 3130.

If the intensivist determines that the sedation score is not less thanor equal to the last Sed Scr after sedative decrease 3116, theintensivist is prompted to determine whether the patient is clinicallyoversedated 3118. If this criterion is met, the intensivist is promptedto determine whether the patient has been sedated for more than 72 hoursand to follow the procedures described above in 3130. If this criterionis not met, the intensivist is prompted to reassess sedation in 1 hr3120.

Referring to FIG. 39, the respiratory isolation decision supportalgorithm is illustrated. If an intensivist determines that there may bea need for respiratory isolation, the intensivist may not be certain ofall aspects that would be involved in this process. Therefore, theintensivist is lead through a decision support algorithm which promptsthe intensiviat to determine the need for respiratory isolation basedupon: a) clinical assessment; and/or b) smear/culture findings 3500.

Pursuing the clinical assessment branch of the decision supportalgorithm, the intensivist is prompted to determine whether the patienthas known mTB (mycobacterium tuberculosis) 3502. If this criterion ismet, the intensivist is prompted to determine whether the patient hasbeen compliant with their medications for over 2 weeks and is clinicallyresponding 3512. If the patient has not been compliant with theirmedications for over 2 weeks and is not clinically responding 3512, theintensivist is prompted that isolation is required 3514. If the patienthas been compliant with their medications and is clinically responding3512, the intensivist is prompted that no isolation is required 3516.

Alternatively, if the patient does not have known mTB 3502, theintensivist is prompted to determine whether the patient has knownmycobacterial disease other than TB 3504. If this criterion is met, theintensivist is prompted to determine whether the patient has new CXR(chest x ray) findings and symptoms (cough 2 weeks, fever, weight loss)3518. If the patient does not have new CXR findings and symptoms 3518,the intensivist is prompted that no isolation is required 3520. If thepatient does have new CXR findings and symptoms 3518, the intensivist isprompted that isolation is required 3522.

If the patient does not have known mycobacterial disease other than TB3504, the intensivist is prompted to determine whether there is a newcavitary lesion on CXR 3506. If this criterion is met, the intensivistis prompted that isolation is required 3524.

Alternatively, if there is no new cavitary lesion on CXR 3506, theintensivist is prompted to determine whether there are pulmonaryinfiltrates or whether the patient is HIV (human immunodeficiency virus)positive 3508. If neither of these criteria is met, the intensivist isprompted that no isolation is required 3510. If either of these criteriais met, the intensivist is prompted to determine whether the patient hasnew CXR findings and symptoms (cough 2 weeks, fever, weight loss) and athigh risk: 1) known mTB exposure; 2) homeless; 3) prisoner; 4) travel toarea with multi-drug resistant TB 3526. If these criteria are met, theintensivist is prompted that isolation is required 3528. Alternatively,if these criteria are not met, the intensivist is prompted that noisolation is required 3530.

Pursuing the smear/culture branch of the decision support algorithm3500, the intensivist is prompted to determine whether the AFB(acid-fast bacilli) smear is positive 3532. If the AFB smear is notpositive, the intensivist is prompted that: no isolation is required;await culture results; if culture negative, no isolation required; ifculture positive and patient has mycobacterial disease other than TB(MOTT no isolation is required; if the culture is positive and thepatient does not have MOTT consult ID 3534.

Alternatively, if the AFB smear is positive, the intensivist is promptedto determine whether the patient has known mycobacterial disease otherthan TB 3536. If this criterion is not met, the intensivist is promptedthat isolation is required 3538. If this criterion is met, theintensivist is prompted: to isolate until results of NAP test are in; ifmTB positive isolate the patient; if no mTB, no isolation is required3540.

Referring to FIG. 40, the empiric meningitis treatment decision supportalgorithm of the present invention is illustrated. If the intensivist istreating a patient for meningitis, the intensivist is prompted to answera series of queries by the system to properly address medication anddosage. First, the intensivist is prompted to determine whether thepatient has suffered a head trauma or undergone neurosurgery 3700. Theanswer to this question is input 1 to table x below. The intensivist isnext prompted to determine whether the patient is allergic to penicillinor is from an area where penicillin resistant staphylococcus pneumoniaeis prevalent 3702. The answer to this question becomes input 2 to tablex below. The intensivist must also determine whether the patient isimmunocompromised 3704, and the answer becomes input 3 to table x below.The intensivist determines if the patient is over fifty years of age3706, with the answer being input 4 in table x below. Lastly, theintensivist is prompted to determine whether the patient has alteredmental status 3708, and the answer becomes input 5 in table x below. Theinputs to each of these prompts 3702, 3704, 3706, 3708 is compared to adosage database according to the Table 5 below.

TABLE 5 Meningitis Input-Output Table Input Combinations Output 1 1 =yes A) vancomycin 2 = no 1.5-2 gm IV q 12 h + ceftazedine 2 gm IV q 8 hror cefapime 2 gm IV q 8 hr 2 1 = yes B) vancomycin 2 = no 1.5-2 gm IV q12 h + aztreonam 0.5-2 gm IV q 6-8 hr 3 1 = no ampicillin 2 gm IV q 4h + 2 = no ceftriaxone 2 gm IV q 12 3 = no cefotaxime 2 gm IV q 6 h 4 =yes 4 1 = no ceftriaxone 2 gm IV q 12 hr 2 = no or 3 = no cefotaxime 2gm IV q 6 hr 4 = no 5 1 = no ampicillin 2 gm IV q 4 hr + 2 = noceftazidime 2 gm IV q 8 hr 3 = yes or cefipime 2 gm IV q 8 hr 6 1 = novancomycin 1.5-2 gm IV q 12 hr + 2 = yes chloramphenicol 1 gm IV q 6 hr3 = no 4 = yes 7 1 = no 2 = yes 3 = no 4 = no 8 1 = no 2 = yes 3 = yes 95 yes to inputs add to output 3-8 consider acyclovir 10 mg/kg IV q 8 h

In the Meningitis Input-Output Table, possible combinations of the fiveinputs are listed. For the conditions manifested in the patient,different drugs and dosages will be required. The proper treatment foreach combination is listed in the output column of Table 5. After thealgorithm runs the comparison, the output is displayed on the computerscreen, prompting the intensivist with the proper treatment 3712.

Referring to FIG. 41A, the ventilator weaning decision support algorithmof the present invention is illustrate The ventilator weaning decisionsupport algorithm is used to determine whether an intensive care unitpatient can return to breathing unassisted, and discontinue use of aventilator. Such a determination weuires evaluation of the patient bythe intensivist over the course of several days.

To begin the decision process of whether to wean a patient fromventilator use, the intensivist is prompted to conduct daily screening,preferably during the hours of 06:00 a.m. to 10:00 a.m. 3800. The dailyscreen prompts the intensivist to determine whether: the patients P/Fratio is greater than 200, the patient's positive end-expiratorypressure (PEEP) is less than or equal to 5, whether cough suctioning hasbeen adequate and/or spontaneous, infusions with vasopressors have beennecessary, and continuous infusions of sedatives or neuromuscularblocking agents have been necessary 3800. If all conditions 3802 areanswered no, the intensivist is directed by the system to repeat thedaily screen 3805 the following morning. If all the conditions of thedaily screen are met 3802, the intensivist is prompted to performadditional tests.

If the patient has satisfied the daily screen, the intensivist is nextdirected to conduct a rapid shallow breathing test 3804. To perform thetest, the intensivist is directed to change the ventilator setting tocontinuous positive airway pressure (CPAP) less than or equal to 5. Inother words, there is no intermittent mandatory ventilation or pressuresupport provided for the patient. The patient is given one minute toreach a steady state of breathing. Then the intensivist measures theratio of breaths per minute to tidal volume (f/V.sub.T). The intensivistnext is prompted to determine whether the patient's f/V.sub.T is lessthan or equal to 105 breathes per minute 3806. If the patient'sf/V.sub.T is greater than 105 breathes per minute, the intensivist isprompted to return to performing daily screening the following morning3808.

If the patient's f/V.sub.T is less than or equal to 105 breathes perminute, the intensivist is next directed to perform a trial ofspontaneous breathing. Here, the intensivist can either insert a T-Piecein the patient's airway or reduce the patient's CPAP to less than orequal to 5 over the course of two hours. The intensivist is prompted toobserve the patient periodically in order to evaluate if the patient isbreathing without assistance 3810. The intensivist is prompted toperform a periodic assessment by determining whether: the patient'sbreathing characteristics are greater than 35 breaths per minute for 5minutes, or SpO.sub.2 is less than 90%, or the patient's Heart Rate (HR)is grater than 140, or HR deviates from the baseline breathing rate bymore than 20%, or the patient's SBP is outside the range of 90 to 180.If any of the conditions are met, the intensivist is directed by thesystem to terminate ventilator weaning 3812. If the conditions are notmet, the patient is further assessed.

In further assessment, the intensivist is prompted to determine whetherthe patient has been able to breathe spontaneously for two hours, keep aclear airway, and does not have any procedures scheduled withintwenty-four hours that would require the patient to be intubated 3814.If the patient meets all of these criteria 3814, the intensivist isnotified by the system that the patient may be extubated 3816. If thepatient does not meet one or more of the criteria 3814, the intensivistis prompted to perform steps for progressive weaning 3818.

Referring to FIG. 41B, the ventilator weaning decision support algorithmof the present invention is further illustrated. The intensivist, at hisor her discretion may choose either T-piece progressive weaning orpressure support progressive weaning. In order to perform T-pieceprogressive weaning, the intensivist is directed to repeat the trial ofspontaneous breathing (as previously described 3810). The intensivistcan either insert a T-piece in the patient's airway or reduce thepatient's CPAP to less than or equal to 5 over the course of two hours.The intensivist is prompted to perform periodic assessment of thepatient by either a two hour or 30 minute trial 3820.

In order to perform pressure support progressive weaning, theintensivist is first prompted to observe whether the patient's pressuresupport (PS) rating is equal to eighteen plus or minus the positiveend-expiratory pressure (PEEP). Next, the intensivist is directed by thesystem to regulate the pressure values in order to keep the patient'srespiratory rate (RR) between twenty and thirty. Next, the intensivistis directed by the system to decrease the patient's pressure support by2-4 centimeters of water two times per day. Once the patient maintainspressure support for at least two hours, the intensivist is prompted tofurther pursue extubating the patient 3822.

After either T-Piece progressive weaning 3820 or pressure supportprogressive weaning 3822, the intensivist is next prompted to perform aperiodic assessment of the patient. Here, the intensivist must determinewhether whether: the patient's breathing characteristics are greaterthan 35 breaths per minute for 5 minutes, or SpO.sub.2 is less than 90%,or the patient's HR is grater than 140, or HR deviates from the baselinebreathing rate by more than 20%; or the patient's SBP is outside therange of 90 to 180. Where the patient meets any of these criteria, theintensivist is prompted to terminate weaning. If the patient meets noneof these criteria; the intensivist is prompted to further assess thepatient's ability to breath spontaneously 3824.

In further assessment, the intensivist is prompted to determine whetherthe patient has been able to breathe spontaneously for two hours, keep aclear airway, and does not have any procedures scheduled withintwenty-four hours that would require the patient to be intubated 3826.If the patient meets all of these criteria 3814, the intensivist isnotified by the system that the patient may be extubated 3828. If thepatient does not meet one or more of the criteria 3826, the intensivistis directed by the system to allow the patient to rest for at leasttwelve hours at A/C, the last level of pressure support the patientachieved 3830. The intensivist is prompted to resume progressive weaningthe following day 3832.

Referring to FIG. 42, the Warfarin Dosing Algorithm of the presentinvention is illustrated. The intensivist is first prompted to give theinitial dose and determine subsequent dosage each day 3900. When theintensivist determines subsequent dosage, he is first prompted todetermine the patient's target INR 3902. If the patient's target INRranges from 2.0 to 3.0, the intensivist is prompted by the system tomake further determinations relevant to dosage. The intensivist isdirected by the system to determine whether the patient is taking drugsthat effect prothrombin time 3904, the baseline INR value 3906, andwhether rapid anticoagulation is required 3908. Each answer is assigneda point value, and the total points are tabulated. If the point value isgreater than one, the system refers to the 10 milligram load targetdatabase for dosing. If the point value is less than one, the systemrefers to the 5 milligram load target database for dosing 3910.

At the initial INR determination 3902, if the patient's INR wasinitially between 1.5 and 2.0, the system refers to the 5 milligram loadtarget database for dosing. If the patient's INR was initially between3.0 and 4.0, the system refers to the 10 milligram load target databasefor dosing 3910. Next the intensivist is prompted to enter the day oftreatment 3912 and the patient's INR 3914. Depending on whether thesystem has been directed to the 5 milligram load target or the 10milligram load target, a comparison is run 3916 according to thefollowing tables.

TABLE 6 5 mg Load Target INR 1.5-2.0 Day <1.5 1.5-2 2-2.5 >2.5 2 51.25-2.5 0 0 3 5-7.5 1.25-2.5 0-1.25 0 4 10- (Check to see 1.25-2.50-1.25 0 whether pt has received vit K) 5 10 2.5-5  0-2.5  0-1.25 (Checkto see whether pt Has received vit K) 6 15 2.5-5  1.25-2.5    0-1.25Obtain hematology consultation.

TABLE 7 10 mg Load Target INR 3.0-4.0 Day <1.5 1.5-2 2-2.5 2.5-3 >3 2 107.5-10 5-7.5 2.5-5.0      0-2.5 3 10-15 7.5-10 5-7.5 2.5-5    2.5-5 410-15   7.5-12.5 5-10  5-7.5 2.5-5 (Check to see whether pt has receivedvit K) 5 15    10-12.5 7.5-10    5-7.5 2.5-5 (Check to see whether pthas received vit K) 6 15-20 obtain  10-15 7.5-12.5  5-10     5-7.5hematology consultation.

The appropriate dosage and instructions is displayed on the computerscreen to the intensivist 3918.

Referring to FIG. 43, the heparin-induced thrombocytopenia (HIT)decision support algorithm of the present invention is illustrated. Theintensivist is prompted to observe whether the patient's platelet counthas dropped 50% or more over seventy-two hours while being treated withheparin, and whether any other obvious causes of platelet reductionmight be present 4100. If such a drop has not occurred, the intensivistis notified by the system that the patient most likely does not haveHIT, but monitoring of the platelet count should continue 4102. If thepatient's platelet count has drastically dropped, the intensivist isprompted to determine whether the patient has been treated with heparinfor more than three days 4104. Regardless of the answer, the intensivistis next prompted to determine if the patient has been treated withheparin in the preceeding three months 4106. If the patient has notreceived heparin in the proceeding three months, the intensivist isnotified by the system that HIT is not likely to be the cause of theplatelet drop. The intensivist is also prompted to monitor plateletcount for infection or other thronbocytopenia-causing drugs, and toconsider stopping heparin therapy if the platelet count drops below50,000 per cubic millimeter 4108.

If the patient has received heparin in the last three days 4104, theintensivist is further prompted to look for signs of thrombosis, orblood clotting 4110. If the patient shows signs of thrombosis, theintensivist is notified by the system that the patient is likely to haveHIT. Accordingly, the intensivist is prompted to stop administeringheparin and flush any drug administration equipment that would containheparin traces. The intensivist is also provided instructions by thesystem to treat a patient still requiring anticoagulation treatment withalternate drugs and methods 4112.

Where the patient does not show signs of thrombosis 4110, theintensivist is prompted to check for heparin resistance 4114. Signs ofheparin resistance include inability to hold aPTT though heparin doseshave been increase. If the patient shows signs of heparin resistance,the intensivist is prompted to consider stopping heparin treatment andto consider treating a patient still requiring anticoagulation treatmentwith alternate drugs and methods 4116. If the patient does not showsigns of heparin resistance, the intensivist is notified by the systemthat the patient possibly has HIT. The intensivist is accordinglyprompted to continue monitoring for thrombosis, consider infection orother drugs that cause throbocytopenia, and to consider stopping heparintherapy if the platelet count drops below 50,000 per cubic millimeter4118

RESULTS

The structure of the present invention and its efficacy have yieldedstriking results in practice. In a research setting, deployment ofcertain rudimentary aspects of the present the invention designed toexperimentally test the approach described and developed in detailabove, yielded unprecedented improvements in clinical and economicoutcomes: 50% improvement in severity adjusted mortality, 40%improvement in clinical complication rates, 30% improvement in ICUlength of stay, and 30% improvement in overall ICU cost of care.

A remote command center for providing services to geographicallydispersed hospitalized patients has been shown. It will be apparent tothose skilled in the art that other variations of the present inventionare possible without departing from the scope of the invention asdisclosed. For example, one can envision different ratios of commandcenter/remote location to ICU's, other decision support algorithms thatwould be used by intensivists, other types of remote monitoring of notonly geographically dispersed hospitalized patients but other types ofhospital functions as well as industrial functions where criticalexpertise is in limited supply but where that expertise must be appliedto ongoing processes. In such cases a system such as that described canbe employed to monitor processes and to provide standardizedinterventions across a number of geographically dispersed locations andoperations. Further, any reference to claim elements in the singular,for example, using the articles “a,” “an,” or “the” is not to beconstrued as limiting the element to the singular.

1. A system for providing alerts to a remote command center alertsconcerning patients in geographically separate health care locations(HCLs) comprising: a network, the remote command center; wherein thenetwork is connected to the remote command center and wherein thenetwork is configured to provide the remote command center access to: adatabase; monitoring stations located in the geographically separatehealth care locations, comprising instructions for obtaining monitoredpatient data elements, wherein the monitored patient data elements arecommunicated to the database via the network, and wherein the databasecomprises stored patient data elements comprising the monitored patientdata elements and other patient data elements associated with medicalconditions of the patients; a computerized patient care managementsystem, wherein the computerized patient care management systemcomprises instructions for: accessing patient data elements from thestored patient data elements; utilizing a rules engine to apply rulesrepeatedly and automatically to at least two patient data elementsaccording to the rules of the rules engine whenever the patient caremanagement system is in operation, wherein the rules applied by therules engine identify existing or potential patient conditions; whereinthe rules applied by the rules engine identify existing or potentialpatient conditions; using information generated by the rules engine todetermine if an alert should be provided to the remote command center;and providing alerts to be concurrently displayed at the remote commandcenter for all patients for whom the computerized patient caremanagement system determines that an alert should be displayed at thattime.
 2. The system of claim 1, wherein a rule comprises an algorithm.3. The system of claim 1, wherein the at least two patient data elementscomprise a physiological data element of the HCL patients and a clinicaldata element of the HCL patients.
 4. The system of claim 1, wherein theat least two patient data elements comprise a physiological data elementof the HCL patients and a medication data element of the HCL patients.5. The system of claim 1, wherein the at least two patient data elementscomprise a physiological data element of the HCL patients and alaboratory data element of the HCL patients.
 6. The system of claim 1,wherein the at least two patient data elements comprise a clinical dataelement of the HCL patients and a laboratory data element of the HCLpatients.
 7. The system of claim 1, wherein the at least two patientdata elements comprise a physiological data element of the HCL patientsand another physiological data element of the HCL patients.
 8. Thesystem of claim 1, wherein the at least two patient data elementscomprise at least two data elements of the HCL patients selected fromthe group consisting of a physiological data element, a clinical dataelement of the HCL patients, a medication data element of the HCLpatients, and a laboratory data element of the HCL patients.
 9. Thesystem of claim 1 wherein the at least two data elements are selectedfrom the group consisting of laboratory data, clinical data,microbiology/antibiotic data, medication data, catheter data, druginfusion data, event data, a radiographic report, a diagnosis, and trenddata.
 10. The system of claim 1 wherein the remote command centerfurther comprises a display wherein the stored patient data elementscomprise vital sign data and wherein the computerized patient caremanagement system further comprises instructions for displaying currentand historical vital sign data on the display.
 11. The system of claim1, wherein the remote command center further comprises a decisionsupport module, wherein the decision support module comprisesinstructions for: accessing a decision support algorithm; applying thedecision support algorithm to the stored patient data elements of an HCLpatient; applying the decision support algorithm to user input; andproviding patient care advice based on the user input.
 12. The system ofclaim 11, wherein the decision support algorithm comprises a guidelineselected from the list consisting of: Acalculous Cholecystitis, AcutePancreatitis Algorithms, Acute Renal Failure-Diagnosis, Acute RenalFailure-Management & Treatment, Adrenal Insufficiency, Agitation andAnxiety, Depression & Withdrawal, Aminoglycoside Dosing and TherapeuticMonitoring, Amphotericin-B Treatment Guidelines, Analgesia, AntibioticClassification & Costs, Antibiograms Algorithm, Antibiotic associatedColitis Algorithm, ARDS: Hemodynamic Management, ARDS: Steroid Use,ARDS: Ventilator Strategies, Asthma, Bleeding Patient, BloodstreamInfections, Blunt Cardiac Injury, Bradyarrhythmias, Brain Death,Bronchodilator Use in Ventilator Patients, Bronchoscopy & ThoracentesisGuidelines, Candiduria, Cardiogenic Shock, CardioPulmonary ResuscitationGuideline, Catheter Related Septicemia, Catheter Replacement Strategies,Cervical Cord Injury, Congestive Heart Failure, COPD Exacerbation &Treatment, CXR (Indications), Dealing with Difficult Patients andFamilies, Diabetic Ketoacidosis, Dialysis, Diuretic Use, Drug Changeswith Renal Dysfunction, Emergency Cardiac Pacing, Endocarditis Diagnosisand Treatment, Endocarditis Prophylaxis, End of Life Decisions,Endotracheal Tubes & Tracheotomy, Ethical Guidelines, FebrileNeutropenia, FUO, Fluid Resuscitation, Guillain-Barre Syndrome, Heparin,Heparin-Induced Thrombocytopenia, Hepatic Encephalopathy, HepaticFailure, HIV+Patient Infections, Hypercalcemia Diagnosis and Treatment,Hyperglycemia Insulin Treatment, Hyperkalemia: Etiology & Treatment,Hypernatremia: Etiology & Treatment, Hypertensive Crisis, Hypokalemia:Etiology & Treatment, Hyponatremia: Etiology & Treatment, Hypothermia,Identification of Cervical Cord Injury, ImplantableCardio-defibrillator, Intra-Aortic Balloon Device, IntracerebralHemorrhage, Latex Allergy, Magnesium Administration, Management ofHypotension, Inotropes, Management of Patients with Ascites, EmpiricMeningitis, Meningitis, a Myasthenia Gravis, Myocardial Infarction,Myocardial Infarction with left bundle branch block, Necrotizing SoftTissue Infections, Neuromuscular Blockers, Neuromuscular Complicationsof Critical Illness, Non-Infectious Causes of Fever, Non-Traumatic Coma,Noninvasive Modes of Ventilation, Nutritional Management, ObstetricalComplication, Oliguria, Open Fractures, Ophthalmic Infections, OrganProcurement Guidelines, PA Catheter Guidelines and Troubleshooting,Pancreatitis, Penetrating Abdominal Injury, Penetrating Chest Injury,Penicillin Allergy, Permanent Pacemaker and Indications, PneumoniaCommunity Acquired, Pneumonia Hospital Acquired, Post-Op Bleeding,Post-Op Hypertension, Post-Op Management of Abdominal Post-Op Managementof Carotid, Post-Op Management of Open Heart, Post-Op Management ofThoracotomy, Post-Op Myocardial Ischemia (Non-Cardiac Arrhythmias afterCardiac Surgery), Post-Op Power Weaning, Pressure Ulcers, PulmonaryEmbolism Diagnosis, Pulmonary Embolism Treatment, Respiratory Isolation,Sedation, Seizure, Status Epilepticus, Stroke, Sub-Arachnoid Hemorrhage,Supra-Ventricular Tachyarrhythmia, Supra-Ventricular Tachycardia, WideComplex QRS Tachycardia, Therapeutic Drug Monitoring, Thrombocytopenia,Thrombolytic Therapy, Transfusion Guidelines, Traumatic Brain Injury,Assessment of Sedation, Sedation, Septic Shock, Bolus Sliding, ScaleMidazolam, Short Term Sedation Process, Sinusitis, SIRS, Spinal CordInjury, Steroid Replacement Strategy, Thyroid Disease, TransplantInfection Prophylaxis, Transplant Related Infections, Treatment ofAirway Obstruction, Unknown Poisoning, Unstable Angina, Upper GIBleeding Stress Prophylaxis, Vancomycin, Upper GI Bleeding Non-Variceal,Upper GI Bleeding Variceal, Use of Hematopoietic Growth Factors,Ventilator Weaning, Ventilator Weaning Protocol, Venous ThrombosisDiagnosis and Treatment, Venous Thromboembolism Prophylaxis, VentricularArrhythmia, Warfarin, Warfarin Dosing, and Wound Healing Strategies. 13.The system of claim 11, wherein the patient care advice is a diagnosis.14. The system of claim 11, wherein the patient care advice is a methodof treatment.
 15. The system of claim 11, wherein the patient careadvice is an order for a laboratory protocol.
 16. The system of claim11, wherein the decision support module further comprises instructionsfor: accessing an order writing module; applying the order writingmodule to the stored patient data elements for an HCL patient; andissuing an order based on the stored patient data elements.
 17. Thesystem of claim 16, wherein the order comprises authorization toadminister medication to the HCL patient.
 18. The system of claim 16,wherein the order comprises authorization to subject the HCL patient toa diagnostic procedure selected from the group consisting of alaboratory protocol, a ventilator protocol, a hemodynamic protocol, anda radiology test.
 19. The system of claim 16, wherein the ordercomprises authorization to subject the HCL patient to a treatmentprocedure selected from the group consisting of a radiological procedureand a surgical procedure.
 20. The system of claim 1, wherein the networkis further configured for receiving video from the HCLs via the network.21. The system of claim 1, wherein the network is further configured forreceiving audio from the HCLs via the network.
 22. The system of claim1, wherein the network is selected from the group consisting of a wirednetwork, a wireless network, a cable network, a fiber optic network, andthe Internet.
 23. The system of claim 1, wherein the remote commandcenter further comprises: an external network interface, wherein theexternal network interface comprises instructions for connecting to anexternal network; and instructions for providing a health care provideraccess to the remote command center via the external network.
 24. Thesystem of claim 23, wherein the external network is selected from thegroup consisting of a wired network, a wireless network, a cablenetwork, a fiber optic network, and the Internet.
 25. The system ofclaim 23, wherein the remote command center further comprisesinstructions for sending the health care provider the alerts provided atthe remote command center.
 26. The system of claim 1, wherein the rulesengine applies the rules in a time-driven fashion.
 27. The system ofclaim 1, wherein the rules engine applies the rules in an event-drivenfashion.
 28. The system of claim 1, wherein the monitored patient dataelements are physiological data elements.
 29. The system of claim 1,wherein the other patient data elements associated with the medicalconditions of the HCL patients are selected from the group consisting ofpatient medical histories, physician notes, lab reports and medications.30. The system of claim 1, wherein the HCL is selected from the groupconsisting of a hospital, an ICU, an operating room, and an emergencyroom.
 31. The system of claim 1, wherein the separate geographiclocations are locations within a building.
 32. The system of claim 1,wherein the separate geographic locations are locations within differentbuildings.
 33. A method for providing alerts at a remote command center,wherein the remote command center has access to a database, the methodcomprising: obtaining patient data elements from monitoring stationslocated in geographically separate health care locations (HCLs), whereinthe monitoring stations comprise instructions for obtaining monitoredpatient data elements, communicating the monitored patient data elementsto the database via a network, wherein the database comprises storedpatient data elements comprising the monitored patient data elements andother patient data elements associated with medical conditions of theHCL patients; receiving at the remote command center alerts, wherein thealerts are provided by a computerized patient care management system,which system utilizes a rules engine to apply rules, repeatedly andautomatically to at least two patient data elements according to therules of the rules engine whenever the patient care management system isin operation, wherein the rules applied by the rules engine identifyexisting or potential patient conditions that may warrant management bya health care provider, and wherein the computerized patient caremanagement system: uses information generated by the rules engine todetermine if an alert should be provided, and provides alerts to beconcurrently displayed at the remote command center for all patients forwhom the computerized patient care management system determines that analert should be displayed at that time.
 34. The method of claim 33,wherein a rule comprises an algorithm.
 35. The method of claim 33,wherein the at least two patient data elements comprise a physiologicaldata element of the HCL patients and a clinical data element of the HCLpatients.
 36. The method of claim 33, wherein the at least two patientdata elements comprise a physiological data element of the HCL patientsand a medication data element of the HCL patients.
 37. The method ofclaim 33, wherein the at least two patient data elements comprise aphysiological data element of the HCL patients and a laboratory dataelement of the HCL patients.
 38. The method of claim 33, wherein the atleast two patient data elements comprise a clinical data element of theHCL patients and a laboratory data element of the HCL patients.
 39. Themethod of claim 33, wherein the at least two patient data elementscomprise a physiological data element of the HCL patients and anotherphysiological data element of the HCL patients.
 40. The method of claim33, wherein the at least two patient data elements comprise at least twodata elements of the HCL patients selected from the group consisting ofa physiological data element, a clinical data element of the HCLpatients, a medication data element of the HCL patients, and alaboratory data element of the HCL patients.
 41. The method of claim 33,wherein monitored data elements comprise physiological data elements.42. The method of claim 33 further comprising: obtaining video of thepatients who are located in the geographically separate health carelocations (HCLs); and accessing at the remote command center the videofrom the patients in the geographically separate HCLs.
 43. The method ofclaim 33, wherein patient data elements are selected from the groupconsisting of laboratory data, clinical data, microbiology/antibioticdata, medication data, catheter data, drug infusion data, event data, aradiographic report, a diagnosis, and trend data.
 44. The method ofclaim 33, wherein the stored patient data elements comprise vital signdata and wherein the method further comprises displaying current andhistorical vital sign data.
 45. The method of claim 33, the methodfurther comprising: accessing a decision support algorithm; applying thedecision support algorithm to the stored patient data elements of theHCL patients; applying the decision support algorithm to user input; andproviding patient care advice based on the user input.
 46. The method ofclaim 45, wherein the decision support algorithm comprises a guidelineselected from the list consisting of: Acalculous Cholecystitis, AcutePancreatitis Algorithms, Acute Renal Failure-Diagnosis, Acute RenalFailure-Management & Treatment, Adrenal Insufficiency, Agitation andAnxiety, Depression & Withdrawal, Aminoglycoside Dosing and TherapeuticMonitoring, Amphotericin-B Treatment Guidelines, Analgesia, AntibioticClassification & Costs, Antibiograms Algorithm, Antibiotic associatedColitis Algorithm, ARDS: Hemodynamic Management, ARDS: Steroid Use,ARDS: Ventilator Strategies, Asthma, Bleeding Patient, BloodstreamInfections, Blunt Cardiac Injury, Bradyarrhythmias, Brain Death,Bronchodilator Use in Ventilator Patients, Bronchoscopy & ThoracentesisGuidelines, Candiduria, Cardiogenic Shock, CardioPulmonary ResuscitationGuideline, Catheter Related Septicemia, Catheter Replacement Strategies,Cervical Cord Injury, Congestive Heart Failure, COPD Exacerbation &Treatment, CXR (Indications), Dealing with Difficult Patients andFamilies, Diabetic Ketoacidosis, Dialysis, Diuretic Use, Drug Changeswith Renal Dysfunction, Emergency Cardiac Pacing, Endocarditis Diagnosisand Treatment, Endocarditis Prophylaxis, End of Life Decisions,Endotracheal Tubes & Tracheotomy, Ethical Guidelines, FebrileNeutropenia, FUO, Fluid Resuscitation, Guillain-Barre Syndrome, Heparin,Heparin-Induced Thrombocytopenia, Hepatic Encephalopathy, HepaticFailure, HIV+Patient Infections, Hypercalcemia Diagnosis and Treatment,Hyperglycemia Insulin Treatment, Hyperkalemia: Etiology & Treatment,Hypernatremia: Etiology & Treatment, Hypertensive Crisis, Hypokalemia:Etiology & Treatment, Hyponatremia: Etiology & Treatment, Hypothermia,Identification of Cervical Cord Injury, ImplantableCardio-defibrillator, Intra-Aortic Balloon Device, IntracerebralHemorrhage, Latex Allergy, Magnesium Administration, Management ofHypotension, Inotropes, Management of Patients with Ascites, EmpiricMeningitis, Meningitis, a Myasthenia Gravis, Myocardial Infarction,Myocardial Infarction with left bundle branch block, Necrotizing SoftTissue Infections, Neuromuscular Blockers, Neuromuscular Complicationsof Critical Illness, Non-Infectious Causes of Fever, Non-Traumatic Coma,Noninvasive Modes of Ventilation, Nutritional Management, ObstetricalComplication, Oliguria, Open Fractures, Ophthalmic Infections, OrganProcurement Guidelines, PA Catheter Guidelines and Troubleshooting,Pancreatitis, Penetrating Abdominal Injury, Penetrating Chest Injury,Penicillin Allergy, Permanent Pacemaker and Indications, PneumoniaCommunity Acquired, Pneumonia Hospital Acquired, Post-Op Bleeding,Post-Op Hypertension, Post-Op Management of Abdominal Post-Op Managementof Carotid, Post-Op Management of Open Heart, Post-Op Management ofThoracotomy, Post-Op Myocardial Ischemia (Non-Cardiac Arrhythmias afterCardiac Surgery), Post-Op Power Weaning, Pressure Ulcers, PulmonaryEmbolism Diagnosis, Pulmonary Embolism Treatment, Respiratory Isolation,Sedation, Seizure, Status Epilepticus, Stroke, Sub-Arachnoid Hemorrhage,Supra-Ventricular Tachyarrhythmia, Supra-Ventricular Tachycardia, WideComplex QRS Tachycardia, Therapeutic Drug Monitoring, Thrombocytopenia,Thrombolytic Therapy, Transfusion Guidelines, Traumatic Brain Injury,Assessment of Sedation, Sedation, Septic Shock, Bolus Sliding, ScaleMidazolam, Short Term Sedation Process, Sinusitis, SIRS, Spinal CordInjury, Steroid Replacement Strategy, Thyroid Disease, TransplantInfection Prophylaxis, Transplant Related Infections, Treatment ofAirway Obstruction, Unknown Poisoning, Unstable Angina, Upper GIBleeding Stress Prophylaxis, Vancomycin, Upper GI Bleeding Non-Variceal,Upper GI Bleeding Variceal, Use of Hematopoietic Growth Factors,Ventilator Weaning, Ventilator Weaning Protocol, Venous ThrombosisDiagnosis and Treatment, Venous Thromboembolism Prophylaxis, VentricularArrhythmia, Warfarin, Warfarin Dosing, and Wound Healing Strategies. 47.The method of claim 45, wherein the patient care advice is a diagnosis.48. The method of claim 45, wherein the patient care advice is a methodof treatment.
 49. The method of claim 45, wherein the patient careadvice is an order for a laboratory protocol.
 50. The method of claim45, wherein the method further comprises: accessing an order writingmodule; applying the order writing module to the stored patient dataelements for an HCL patient; and issuing an order based on the storedpatient data elements.
 51. The method of claim 50, wherein the ordercomprises authorization to administer medication to the HCL patient. 52.The method of claim 50, wherein the order comprises authorization tosubject the HCL patient to a diagnostic procedure selected from thegroup consisting of a laboratory protocol, a ventilator protocol, ahemodynamic protocol, and a radiology test.
 53. The method of claim 50,wherein the order comprises authorization to subject the HCL patient toa treatment procedure selected from the group consisting of aradiological procedure and a surgical procedure.
 54. The method of claim33, wherein the network is selected from the group consisting of a wirednetwork, a wireless network, a cable network, a fiber optic network, andthe Internet.
 55. The method of claim 33 further comprising: interfacingwith an external network; and providing a health care provider access tothe remote command center via the external network.
 56. The method ofclaim 55, wherein the external network is selected from the groupconsisting of a wired network, a wireless network, a cable network, afiber optic network, and the Internet.
 57. The method of claim 55further comprising sending the health care provider the alerts providedat the remote command center.
 58. The method of claim 33, wherein therules engine applies the rules in a time-driven fashion.
 59. The methodof claim 33, wherein the rules engine applies the rules in anevent-driven fashion.
 60. The method of claim 33, wherein the monitoredpatient data elements are physiological data elements.
 61. The method ofclaim 33, wherein the other patient data elements associated with themedical conditions of the HCL patients are selected from the groupconsisting of patient medical histories, physician notes, lab reportsand medications.
 62. The method of claim 33, wherein the HCL is selectedfrom the group consisting of a hospital, an ICU, an operating room, andan emergency room.
 63. The method of claim 33, wherein the separategeographic locations are locations within a building.
 64. The method ofclaim 33, wherein the separate geographic locations are locations withindifferent buildings.
 65. A system for providing at a remote commandcenter alerts about a plurality of ICU patients located ingeographically separate ICUs, comprising: a network; the remote commandcenter; an audio system comprising instructions for obtaining audio ofthe ICU patients who are located in the geographically separate ICUs andfor communicating the audio via the network; a video system comprisinginstructions for obtaining video of the ICU patients who are located inthe geographically separate ICUs and for communicating the video via thenetwork, wherein the audio obtained from the audio system and the videoobtained from the video system are received at the remote commandcenter, and monitoring stations located in the geographically separateICUs, wherein the monitoring stations comprise instructions forobtaining data elements from patients who are located in thegeographically separate ICUs (monitored patient data elements) and forcommunicating the monitored patient data elements to a database via thenetwork; and wherein the network is connected to the remote commandcenter and wherein the network is configured to provide the remotecommand center access to: a database that comprises stored patient dataelements comprising the monitored patient data elements and otherpatient data elements associated with medical conditions of the ICUpatients; a computerized patient care management system, wherein thecomputerized patient care management system comprises instructions for:accessing patient data elements from the stored patient data elements inthe database; utilizing a rules engine to apply rules repeatedly andautomatically to at least two patient data elements according to therules of the rules engine whenever the patient care management system isin operation, wherein the rules applied by the rules engine identifyexisting or potential patient conditions that may warrant management bya health care provider; using information generated by the rules engineto determine if an alert should be provided at the remote commandcenter; and providing alerts to be concurrently displayed at the remotecommand center for all patients for whom the computerized patient caremanagement system determines that an alert should be displayed at thattime.
 66. The system of claim 63, wherein the separate geographiclocations are locations within a building.
 67. The system of claim 63,wherein the separate geographic locations are locations within differentbuildings.
 68. The system of claim 65, wherein the remote command centerfurther comprises a display wherein the stored patient data elementscomprise vital sign data and wherein the computerized patient caremanagement system further comprises instructions for displaying currentand historical vital sign data on the display.
 69. The system of claim65, wherein the at least two patient data elements comprise aphysiological data element of the ICU patients and a clinical dataelement of the ICU patients.
 70. The system of claim 65, wherein the atleast two patient data elements comprise a physiological data element ofthe ICU patients and a medication data element of the ICU patients. 71.The system of claim 65, wherein the at least two patient data elementscomprise a physiological data element of the ICU patients and alaboratory data element of the ICU patients.
 72. The system of claim 65,wherein the at least two patient data elements comprise a clinical dataelement of the ICU patients and a laboratory data element of the ICUpatients,
 73. The system of claim 65, wherein the at least two patientdata elements comprise a physiological data element of the ICU patientsand another physiological data element of the ICU patients.
 74. Thesystem of claim 65, wherein the at least two patient data elementscomprise at least two data elements of the ICU patients selected fromthe group consisting of a physiological data element, a clinical dataelement of the ICU patients, a medication data element of the ICUpatients, and a laboratory data element of the ICU patients.
 75. Thesystem of claim 65 wherein the at least two data elements are selectedfrom the group consisting of laboratory data, clinical data,microbiology/antibiotic data, medication data, catheter data, druginfusion data, event data, a radiographic report, a diagnosis, and trenddata.
 76. The system of claim 65, wherein the monitored patient dataelements are physiological data elements.
 77. The system of claim 65,wherein the other patient data elements associated with the medicalconditions of the ICU patients are selected from the group consisting ofpatient medical histories, physician notes, lab reports and medications.78. The system of claim 65, wherein the rules engine applies the rulesin a time-driven fashion.
 79. The system of claim 65, wherein the rulesengine applies the rules in an event-driven fashion.
 80. A method forproviding at a remote command center alerts about a plurality of ICUpatients located in geographically separate ICUs, wherein the remotecommand center has access to a database, the method comprising:obtaining patient data elements from monitoring stations located in thegeographically separate ICUs, wherein the monitoring stations obtaindata elements from patients who are located in the geographicallyseparate ICUs (monitored patient data elements); communicating themonitored patient data elements to the database via a network, whereinthe database comprises stored patient data elements comprising themonitored patient data elements and other patient data elementsassociated with medical conditions of the ICU patients; obtaining audioof the ICU patients who are located in the geographically separate ICUs;obtaining video of the ICU patients who are located in thegeographically separate ICUs, accessing at the remote command center theaudio and the video of the patients in the geographically separate ICUs;displaying at the remote command center alerts, provided by acomputerized patient care management system, which system utilizes arules engine to apply rules, repeatedly and automatically to at leasttwo patient data elements according to the rules of the rules enginewhenever the patient care management system is in operation, wherein therules applied by the rules engine identify existing or potential patientconditions that may warrant management by a health care provider, andwherein the computerized patient care management system: usesinformation generated by the rules engine to determine if an alertshould be provided, and provides alerts to be concurrently displayed atthe remote command center for all patients for whom the computerizedpatient care management system determines that an alert should bedisplayed at that time; and wherein the alerts are concurrentlydisplayed at the the remote command center for all patients for whom thecomputerized patient care management system determines that an alertshould be displayed at that time.
 81. The method of claim 80, whereinthe separate geographic locations are locations within a building. 82.The method of claim 80, wherein the separate geographic locations arelocations within different buildings.
 83. The method of claim 80,wherein the stored patient data elements comprise vital sign data andwherein the method further comprises displaying current and historicalvital sign data.
 84. The method of claim 80, wherein the at least twopatient data elements comprise a physiological data element of the ICUpatients and a clinical data element of the ICU patients.
 85. The methodof claim 80, wherein the at least two patient data elements comprise aphysiological data element of the ICU patients and a medication dataelement of the ICU patients.
 86. The method of claim 80, wherein the atleast two patient data elements comprise a physiological data element ofthe ICU patients and a laboratory data element of the ICU patients. 87.The method of claim 80, wherein the at least two patient data elementscomprise a clinical data element of the ICU patients and a laboratorydata element of the ICU patients.
 88. The method of claim 80, whereinthe at least two patient data elements comprise a physiological dataelement of the ICU patients and another physiological data element ofthe ICU patients.
 89. The method of claim 80, wherein the at least twopatient data elements comprise at least two data elements of the ICUpatients selected from the group consisting of a physiological dataelement, a clinical data element of the ICU patients, a medication dataelement of the ICU patients, and a laboratory data element of the ICUpatients.
 90. The method of claim 80, wherein patient data elements areselected from the group consisting of laboratory data, clinical data,microbiology/antibiotic data, medication data, catheter data, druginfusion data, event data, a radiographic report, a diagnosis, and trenddata.
 91. The method of claim 80, wherein the monitored patient dataelements are physiological data elements.
 92. The method of claim 80,wherein the other patient data elements associated with the medicalconditions of the ICU patients are selected from the group consisting ofpatient medical histories, physician notes, lab reports and medications.93. The method of claim 80, wherein the rules engine applies the rulesin a time-driven fashion.
 94. The method of claim 80, wherein the rulesengine applies the rules in an event-driven fashion.
 95. A system forsimultaneously managing information associated with the care of patientsin geographically separate health care locations comprising: acomputerized patient care management system comprising access to adatabase and a rules engine; a network in communication with thegeographically separate health care locations and a remote commandcenter over which patient data elements relating to patients in thegeographically separate health care locations can be received by thecomputerized patient care management system via the network, and overwhich patient data elements, and alerts can be communicated to theremote command center via the network; patient data elements stored inthe database, which patient data elements comprise data elementsobtained from patient monitoring stations that monitor patients locatedin the geographically separate health care locations and data elementsassociated with medical conditions of the patients located in thegeographically separate health care locations; wherein the computerizedpatient care management system further comprises instructions for:utilizing the information generated by the rules engine associated withthe patients in the geographically separate health care locations todetermine if an alert should be communicated to the remote command;wherein the rules engine applies rules repeatedly and automatically toat least two patient data elements according to the rules of the rulesengine whenever the patient care management system is in operation toidentify existing or potential patient conditions and communicatingalerts to be concurrently available at the remote command center, viathe network, for all patients in the geographically separate health carelocations for which the computerized patient care management systemdetermines that an alert should be available at that time.
 96. Thesystem of claim 95 wherein utilizing the rules engine occurs 24 hoursper day, 7 days per week.
 97. The system of claim 95, further comprisinginstructions residing in the computerized patient care management systemfor: communicating audio from the geographically separate health carelocations to the remote command center via the network; andcommunicating video from the geographically separate health carelocations to the remote command center via the network.
 98. A system forsimultaneously managing information associated with the care of patientsin geographically separate ICUs comprising: a computerized patient caremanagement system comprising access to a database and a rules engine; anetwork in communication with the geographically separate ICUs and aremote command center over which patient data elements relating topatients in the geographically separate ICUs can be received by thecomputerized patient care management system via the network, and overwhich patient data elements, and alerts can be communicated to theremote command center via the network; patient data elements stored inthe database, which patient data elements comprise data elementsobtained from patient monitoring stations that monitor patients locatedin the geographically separate ICUs and data elements associated withmedical conditions of the patients located in the geographicallyseparate ICUs; wherein the computerized patient care management systemfurther comprises instructions for: utilizing the information generatedby the rules engine associated with the patients in the geographicallyseparate ICUs to determine if an alert should be communicated to theremote command; wherein the rules engine applies rules repeatedly andautomatically to at least two patient data elements to identify existingor potential patient conditions; and communicating alerts to beconcurrently available at the remote command center, via the network,for all patients in the geographically separate ICUs for which thecomputerized patient care management system determines that an alertshould be available at that time.
 99. The system of claim 98 whereinutilizing the rules engine occurs 24 hours per day, 7 days per week.100. The system of claim 98, further comprising instructions residing inthe computerized patient care management system for: communicating audiofrom the geographically separate ICUs to the remote command center viathe network; communicating video from the geographically separate healthICUs to the remote command via the network.
 101. The system of claim100, further comprising instructions residing in the computerizedpatient care management system for: causing audio of multiple ICUpatients to be concurrently communicated to the remote command center inresponse to instructions received from the remote command center via thenetwork; and causing video of multiple ICU patients to be concurrentlycommunicated to the remote command center in response to instructionsreceived from the remote command center via the network.